Ellame Ford-Dunn

Before HM Coroner Joanne Andrews
Chart Way Horsham West Sussex RH12 1XH 
Opened and adjourned October 2024
Reopens 26 January 2026, expected to last 6 days

Ellame Ford-Dunn (pronounced ‘El-Ah-Me’), was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. Now an inquest will reopen to examine the circumstances of her death.

Last November, University Hospitals Sussex NHS Foundation Trust (UHST) was fined £200,000 after admitting to health and safety offences relating to Ellame’s death. INQUEST understands this to be the fifth largest fine imposed on an NHS Trust or private provider following a death in a mental health setting.

Ellame was the eldest of three children. She loved swimming in the sea with her brother and dancing with her sister. Her family describe her as a people pleaser who always cared more about other people’s feelings than her own.

Ellame had a long history of trauma, suicidal ideation and self-harm. She was autistic and had ADHD and an eating disorder. She was under the care of Child and Adult Mental Health Services (CAMHS) and had spent over 18 months in inpatient mental health care units.

On 18 January 2022 she was discharged from Chalkhill Hospital with s.117 aftercare. On 28 February 2022, Ellame was informally admitted to Bluefin Ward at Worthing Hospital as a result of self-harm.

A few days later, she was detained under Section 3 of the Mental Health Act after absconding from the hospital and ligaturing. She was placed under 24-hour one-to-one observation by a registered mental health nurse (RMN).

At 8.30pm on 20 March 2022, Ellame absconded from her RMN. Security officers performed a search of the hospital grounds before informing Sussex police.

At 9.30pm, police found Ellame having ligatured in the hospital grounds. An ambulance was called and Ellame was taken into the hospital where she was declared dead shortly after.

The scope of the inquest will examine events from the time of her discharge on 18 January 2022 until and including the events of Ellame’s death on 20 March 2022.

The inquest was previously adjourned in October 2024 pending an investigation by the Care Quality Commission (CQC).

ENDS

NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.

The family are represented by INQUEST Lawyers Group members Ilaria Minucci of Birnberg Peirce and Oliver Lewis of Doughty Street. They are supported by INQUEST Senior Caseworker Jodie Anderson.

Other Interested persons represented are Sussex Partnership NHS Foundation Trust, University Hospitals Sussex NHS Foundation Trust, a Registered Mental Health Nurse (RMN), West Sussex County Council, the Care Quality Commission (CQC), and the NHS Integrated Care Board (ICB).

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Deaths in the care of Sussex mental health services:

• Morgan Betchley was 19 years old when she died after ligaturing whilst a voluntary mental health inpatient at Meadowfield Hospital on 9 March 2023. An inquest found that a series of failings and unprofessional behaviour by staff contributed to Morgan’s death. Media release.
• Morghana Woodburn, 18, died a self-inflicted death at Meadowfield Hospital in January 2018. Morghana was diagnosed with PTSD and EUPD. She was moved seven times between four different hospitals over the nine months leading up to her death. An inquest concluded that she died as a result of her mental health issues which led her to self-harm. Media coverage.
• Matty Sheldrick, a 29 year old autistic person, died on 22 November 2022 after ligaturing outside the Royal Sussex County Hospital. They had left A&E less than two hours before. An inquest into their death resumed this week. Media release.
• Jason Pulman, a 15 year old transgender teenager died a self-inflicted death on 19 April 2022 in East Sussex. An inquest found that systemic failures by all of the organisations involved in his care, with the exception of his school, possibly contributed to his death. Media release.
• Jessie Eastland Seares, 19, died whilst an inpatient at Mill View Hospital in May 2022. Jessie was autistic and had a complex history of neurodevelopmental, physical and mental health issues. A jury found that systemic failures in health and social care led to her death. Media release.
• Rachel Garrett, 22, died after falling from a height in Brighton on 29 July 2020. An inquest found that opportunities to save her life had been missed. Rachel had mental and physical health needs and had spent time in the care of Mill View Hospital. Media release.
• The Telegraph reported in January 2022 that more than 360 patients took their own lives after being treated by Sussex Partnership Foundation NHS Trust in the past five years. While there were also 15 coroner’s reports to prevent future deaths.
• Bethany Tenquist, 26, died after ligaturing in her room at Mill View Hospital on 16 January 2019. An inquest found a sequence of serious failures relating to staffing, leadership and safeguarding processes on ward probably had a direct causal connection to her death. Media release.
• Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care. Media release.
• In 2016, local media reported that five women had died at Mill View Hospital, including Janet Müller (above), Danuta Corbett, Jessica Philpott, Jackie Stansby, and Philippa Mortiz-Parsons.
• Sabrina ‘Sabby’ Walsh, 32, died on the Woodlands Ward in Sussex 2016. The inquest found gross failures and neglect contributed to her death. Media release.
•  Bethan Smith, 31, died whilst under the care of Sussex Partnership Trust in 2011. Her mother wrote this about their experiences.