Brighton Magistrates Court
26 November 2025
A Sussex NHS Trust has today been sentenced after admitting to health and safety offences relating to the death of Ellame Ford-Dunn, a 16 year old mental health inpatient. A judge at Brighton Magistrates Court has now sentence University Hospitals Sussex NHS Foundation Trust (UHST) and imposed a fine of £200,000, none of which will reach Ellame’s family. 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.
The eldest of three children, Ellame (pronounced ‘El-a-mee’) 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 Adolescent Mental Health Services (CAMHS) and had spent over 18 months in inpatient mental health care units.
Ellame died on 20 March 2022 after absconding and ligaturing whilst detained under Section 3 of the Mental Health Act at Bluefin Ward, Worthing Hospital. She was under 24-hour one-to-one observation by a registered mental health nurse.
Last month, University Hospitals Sussex NHS Foundation Trust (UHST) pleaded guilty to the offences of failing to provide safe care and treatment resulting in avoidable harm to Ellame, under regulations 12(1) and 22(2) of the Health and Social Care Act 2008.
The Trust accepted that deficiencies in its policy and guidance to staff on how to respond to a patient who had absconded – in particular, a failure to direct staff to follow an absconding inpatient – exposed Ellame to avoidable harm.
The court heard that whilst under one-to-one observations by an agency nurse, Ellame was seen absconding from the ward. She was not immediately followed and so within a few moments her whereabouts became unknown. Ellame was later found unconscious, having ligatured on the hospital grounds.
The Trust accepted that Bluefin Ward - an acute inpatient ward - was increasingly being used to accommodate mental health patients. The ward was neither trained nor equipped to care for such patients, many of whom were extremely vulnerable. Due to a national shortage of mental health beds, Ellame was placed on Bluefin Ward despite it not being a suitable environment for her care.
In passing sentence today, the District Judge commented that ‘the Trust knew of the risks posed to Ellame, and given the number of times she attempted to leave the ward and previous made attempts on her life, this clear instruction to follow her should have been incorporated in their plan and general policy.’
An inquest into Ellame’s death was adjourned in December 2024 pending the criminal investigation by the Care Quality Commission (CQC).
Responding to the sentencing of the NHS Trust today, Ellame’s parents said: “We are grateful that the CQC has brought this prosecution and also for the Trust’s guilty plea, in recognition of the significant failures in our daughter’s care. This acknowledgement confirms our beliefs that she was failed by a system that was meant to protect her.
Our beautiful Ellame has been described as “a bright firework in a dark sky”. She was a loving, caring soul, with a laugh that drew everyone in. She was deeply loved and is painfully missed.
The loss of Ellame has been devastating, not only for us as a family, but for her wider family, friends and all who loved her.
There is no greater heartbreak than losing a child, but to lose a child you believed was being kept safe creates a pain beyond measure, and a deep, searing anger.
No financial penalty could ever feel proportionate to the destruction that has been caused. We would take some comfort were the Secretary for Health to direct the funds toward strengthening children’s mental health services, an area in such urgent need of support.
We do not want to say more at this stage as we do not want to risk jeopardising the ongoing legal proceedings. This prosecution is an important step in highlighting just one of the many failings in Ellame’s care and brings a first taste of justice on behalf of our darling girl."
You can read the family’s Victim Impact Statement here.
Jodie Anderson, Senior Caseworker at INQUEST, said: “Ellame’s family has waited three years for accountability over her death, and today’s guilty plea marks a significant milestone in their journey. It is a clear acknowledgement of serious failures in her care. While this is an important step in bringing evidence of poor mental health care into the public domain, it must also act as a catalyst for wider systemic change.
We need urgent action to ensure further failures and harms by mental health services are prevented, and to ensure every child and young person in distress receives the care and support they need.”
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 Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Information about Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is available on CQC’s website.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Previous media release: Ellame Ford-Dunn: Inquest to open into self-inflicted death of teenage girl at Worthing Hospital
Ellame Ford-Dunn
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
Brighton Magistrates Court
26 November 2025
A Sussex NHS Trust has today been sentenced after admitting to health and safety offences relating to the death of Ellame Ford-Dunn, a 16 year old mental health inpatient. A judge at Brighton Magistrates Court has now sentence University Hospitals Sussex NHS Foundation Trust (UHST) and imposed a fine of £200,000, none of which will reach Ellame’s family. 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.
The eldest of three children, Ellame (pronounced ‘El-a-mee’) 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 Adolescent Mental Health Services (CAMHS) and had spent over 18 months in inpatient mental health care units.
Ellame died on 20 March 2022 after absconding and ligaturing whilst detained under Section 3 of the Mental Health Act at Bluefin Ward, Worthing Hospital. She was under 24-hour one-to-one observation by a registered mental health nurse.
Last month, University Hospitals Sussex NHS Foundation Trust (UHST) pleaded guilty to the offences of failing to provide safe care and treatment resulting in avoidable harm to Ellame, under regulations 12(1) and 22(2) of the Health and Social Care Act 2008.
The Trust accepted that deficiencies in its policy and guidance to staff on how to respond to a patient who had absconded – in particular, a failure to direct staff to follow an absconding inpatient – exposed Ellame to avoidable harm.
The court heard that whilst under one-to-one observations by an agency nurse, Ellame was seen absconding from the ward. She was not immediately followed and so within a few moments her whereabouts became unknown. Ellame was later found unconscious, having ligatured on the hospital grounds.
The Trust accepted that Bluefin Ward - an acute inpatient ward - was increasingly being used to accommodate mental health patients. The ward was neither trained nor equipped to care for such patients, many of whom were extremely vulnerable. Due to a national shortage of mental health beds, Ellame was placed on Bluefin Ward despite it not being a suitable environment for her care.
In passing sentence today, the District Judge commented that ‘the Trust knew of the risks posed to Ellame, and given the number of times she attempted to leave the ward and previous made attempts on her life, this clear instruction to follow her should have been incorporated in their plan and general policy.’
An inquest into Ellame’s death was adjourned in December 2024 pending the criminal investigation by the Care Quality Commission (CQC).
Responding to the sentencing of the NHS Trust today, Ellame’s parents said: “We are grateful that the CQC has brought this prosecution and also for the Trust’s guilty plea, in recognition of the significant failures in our daughter’s care. This acknowledgement confirms our beliefs that she was failed by a system that was meant to protect her.
Our beautiful Ellame has been described as “a bright firework in a dark sky”. She was a loving, caring soul, with a laugh that drew everyone in. She was deeply loved and is painfully missed.
The loss of Ellame has been devastating, not only for us as a family, but for her wider family, friends and all who loved her.
There is no greater heartbreak than losing a child, but to lose a child you believed was being kept safe creates a pain beyond measure, and a deep, searing anger.
No financial penalty could ever feel proportionate to the destruction that has been caused. We would take some comfort were the Secretary for Health to direct the funds toward strengthening children’s mental health services, an area in such urgent need of support.
We do not want to say more at this stage as we do not want to risk jeopardising the ongoing legal proceedings. This prosecution is an important step in highlighting just one of the many failings in Ellame’s care and brings a first taste of justice on behalf of our darling girl."
You can read the family’s Victim Impact Statement here.
Jodie Anderson, Senior Caseworker at INQUEST, said: “Ellame’s family has waited three years for accountability over her death, and today’s guilty plea marks a significant milestone in their journey. It is a clear acknowledgement of serious failures in her care. While this is an important step in bringing evidence of poor mental health care into the public domain, it must also act as a catalyst for wider systemic change.
We need urgent action to ensure further failures and harms by mental health services are prevented, and to ensure every child and young person in distress receives the care and support they need.”
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 Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Information about Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is available on CQC’s website.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Previous media release: Ellame Ford-Dunn: Inquest to open into self-inflicted death of teenage girl at Worthing Hospital
Make a Donation
Every year, INQUEST supports hundreds of families bereaved by deaths involving the state. We are independent of government and entirely reliant on grants and donations to continue our vital work.
Support us and bereaved families in the fight for truth, justice and accountability by becoming a regular donor today.
Donate now
Related items
Subscribe to our newsletter
To receive the latest news from INQUEST straight into you inbox please subscribe. For examples of what you will receive, see our previous newsletters.