Ellame FORD-DUNN · Prevention of Future Deaths report

On 21 March 2022 I commenced an investigation into the death of Ellame FORD-DUNN aged 16. The investigation concluded at the end of the inquest on 02 February 2026. The narrative conclusion of the inquest by the jury was that:

It was inappropriate for Ellame to be detained on a paediatric ward from 28th February to 20th March 2022 and the risk assessments in place were inadequate and inconsistently applied.

One to one observation was required by the risk assessment and this was provided on the 20th March. Security was not provided on Bluefin ward and there were no means to prevent her absconsion which occurred during a toilet visit. Ellame left the ward by the main exit and was not pursued immediately. Security and Police were notified, but 59 minutes elapsed until she was found by the Police.

The instructions given to agency registered mental health nurses were inadequate, patient notes were held on multiple systems, with access not freely available to agency staff and inadequately transferred during handover.

University Hospital Sussex NHS Foundation Trust policy for missing patients was not designed for high-risk mental health patients and the procedure to be followed in the event of absconsion was unclear and not appropriately communicated.

Death was more than minimally contributed by:

1. Inadequate provision of Tier 4 beds for children with severe mental health difficulties in Sussex and nationally.
2. The decision to detain Ellame on an acute paediatric ward without the provision of security.
3. The inconsistency of nursing handovers and little guidance on how to plan or respond if risk escalated or if Ellame absconded.
4. Poor co-ordination, communication and accountability between multiple agencies providing care for Ellame.

Ellame had previously been a mental health patient at Chalkhill Hospital and had been managed in the community from 18th January 2022 until her admission to Worthing Hospital on 28 February 2022. Ellame was sectioned under Section 3 of the Mental Health Act on 12 March 2022.

Following that assessment, it was determined that Ellame needed admission to a Tier 4 Adolescent Mental Health Bed. As no Tier 4 Paediatric Mental Health beds were available she was detained to Worthing Hospital, which is an acute hospital with a paediatric ward designed for acute paediatric physical medical care.

The ward on which Ellame was detained did not have any facility for the doors to be locked and could be exited by pressing a green door release button. Ellame was nursed on 1:1 observations by a Registered Mental Health Nurse who was supervising her to the toilet when she absconded. Ellame pressed the green button and exited the ward. She was not followed immediately beyond the exit from the Ward into the main corridor. Ellame died ████████
████████ following her absconding from the Ward.

Ellame remained on the Acute Paediatric Ward at Worthing Hospital until her death on 20 March 2022 as there remained no Tier 4 bed available to her in England at that time.

1. I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission. I heard that the waiting time for a bed for those who are under the Kent and Sussex Child and Adolescent Mental Health Services (CAMHS) Inpatient Provider Collaborative is, on average, 8 days.

2. I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to.

3. I heard that at Worthing Hospital the Acute Paediatric Ward has been altered since Ellame’s death but due to fire regulations cannot be locked in the same way as a Tier 4 Paediatric Mental Health Unit would be and is not designed for the admission and treatment of children and young people with mental health concerns. I heard that the staff are not able to provide the mental health care that these patients are considered to require in their setting.