Bed shortage contributed to teen death, jury finds

The shortage of specialist mental health beds "more than minimally contributed" to the death of a 16‑year‑old who died while sectioned, a jury has found.

Ellame Ford‑Dunn took her own life in March 2022 after running away from the Bluefin paediatric ward at Worthing Hospital, where she was being treated as a mental health inpatient.

Jurors at West Sussex Coroner's Court in Horsham said the lack of high-level Tier 4 child mental health beds in Sussex, and nationally, contributed to her death.

The inquest heard Ellame had previously run away from the ward and was under one‑to‑one supervision. Bluefin is a paediatric unit, described as "not ideal" due to no specialist beds being available.

Tier 4 Child and Adolescent Mental Health Services (CAMHS) beds provide the highest‑level inpatient care for children whose needs cannot be managed in the community.

The jury also found the "decision to detain Ellame on an acute paediatric ward without the provision of security" contributed to her death.

"The inconsistency of nursing handovers and little guidance on how to plan or respond if risk escalated or if Ellame absconded" was also considered a factor in her death.

Another contributing factor was "poor co-ordination, communication and accountability between multiple agencies providing care for Ellame", the jury said.

Dr Richard Sankar, clinical director for the NHS-led Hampshire, Isle of Wight, Sussex, Kent and Medway CAMHS Provider Collaborative, said: "We offer our sincere condolences to Ellame's family.

"We acknowledge the delay in identifying a mental health bed for Ellame. Our aim is always to provide people with care that both meets a person's individual needs and is as close as possible to their family and community."

Dr Maggie Davies, chief nurse for University Hospitals Sussex NHS Foundation Trust, said: "The loss of Ellame at such a young age was a tragedy and devastating for everyone who knew and loved her.

"We had a responsibility to protect her while she was in our care, and we are deeply sorry that we were not able to do so.

"Since Ellame's death, we have fundamentally improved the way we care for patients with mental health needs within our hospitals, including additional staff training and stronger security protocols. "

Nancy Ford-Dunn, Ellame's mother, previously told the court her daughter began to struggle with her mental health when she started secondary school, and was diagnosed with autism, ADHD and dyslexia.

They said they felt unsupported when she was discharged from a mental health unit in January 2022 to return home.

After the inquest, she told BBC South East: "We are really grateful that the jury clearly understood all that they had heard in court and we couldn't have asked for a much better conclusion.

"Losing a child is the most devastating thing that can happen to a family and the length of time that it has taken to get this has compounded how difficult that is.

"You're stuck in the before-details, so determined to get the story across, for people to understand all the failings - it's delayed us being able to get to the grieving part."

Her family described Ellame as a "bundle of joy", a "loving sister" and "a bright firework in a dark sky".

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