The parents of a teenage girl who took her own life have condemned ‘devastating failures’ by NHS mental health services which were exposed at her inquest.
Ellame Ford-Dunn, 16, from Upper Beeding in West Sussex, died after ‘inadequate’ care, ‘poor communication’ and how no ‘suitable’ bed could be found, a jury said.
She had absconded ‘multiple times’ during her stay on Bluefin ward at Worthing Hospital, which was not a specialist mental health ward.
The student had been in and out of mental health facilities for several years before finally being discharged home – but was then admitted to hospital in February 2022 after repeatedly self-harming, having also suffered with an eating disorder.
She was placed in a children’s medical ward but was later detained under the Mental Health Act after absconding and attempting to kill herself, being placed under 24-hour one-to-one observation by an agency-provided registered mental health nurse.
On March 20 2022, Ellame told an agency nurse she needed to go to the toilet, before breaking into a run out of Worthing Hospital.
A search of the grounds was launched before Ellame was discovered an hour after she absconded, lying in bushes in the hospital grounds and – despite attempts to save her – she was pronounced dead shortly afterwards.
Her parents Ken and Nancy Ford-Dunn have told how the family was left ‘devastated’ by Ellame’s death – and called for urgent action to give children with mental health issues the care they need.
Ellame Ford-Dunn, 16, from Upper Beeding in West Sussex, took her own life after absconding from Worthing Hospital in West Sussex in March 2022
Her parents Ken and Nancy Ford-Dunn have called for urgent action to give children with mental health issues the care they need
Fighting back tears, her parents said ‘devastating failures’ to provide care for their daughter as well as inadequate training and communication had cost Ellame her life.
Mrs Ford-Dunn said: ‘I can’t brush her hair and paint her nails and wash her clothes. I can’t deal those parenting things that I want to be able to do and so all we’ve got left is this fight – to make sure that everybody understands how badly she was failed.
‘It’s devastating. It’s hard to explain, because you have the devastation you have – it’s overwhelming.’
Mr Ford-Dunn said he had been driven by anger to hold the hospital trusts to account that he felt he had not had time to grieve.
They said there was a lack of co-ordinated care between social services, the hospital trust and specialist mental health services.
The jury at the inquest in Horsham, West Sussex, heard Ellame had enjoyed primary school but began to struggle when she went to secondary school in 2016.
She suffered from severe stress and would often self-harm as her mental health deteriorated.
The hearing was told her parents had difficulty getting her to go to school and despite seeking help they felt there was very little help from medical services.
The student had been in and out of mental health facilities for several years before being discharged home – but was then admitted to hospital in February 2022 after self-harming
As her mental health continued to decline, Ellame, who had ADHD and autism, continued to self-harm and twice tried to take her own life in 2019.
At the start of the Covid-19 pandemic in 2020, she began refusing to eat and was later diagnosed as anorexic.
She was under the care of Child and Adult Mental Health Services (CAMHS) and spent over 18 months in inpatient mental health care units.
in 2021 the teenager confided in her parents that she had been the victim of sexual abuse.
After a spell in the Priory Hospital in Manchester, she was discharged into the care of Chalkhill Hospital, run by the Sussex Partnership NHS Foundation Trust.
She spent several months at the hospital receiving treatment to tackle her self-harming and anorexia.
Ellame’s condition was considered to have improved to such a level that she was discharged from Chalkhill Hospital in January 2022.
As well as a care plan, she was also assigned a paediatric psychiatrist and an initial meeting between them appeared to go well.
Ellame, who had ADHD and autism, twice tried to take her own life in 2019 – and at the start of the pandemic in 2020, she began refusing to eat and was later diagnosed as anorexic
However, the inquest heard that once back at home Ellame’s condition deteriorated rapidly and she began to self-harm and attempted suicide more than once.
She was repeatedly taken to hospital after self-harming but was discharged after treatment several times.
Her mother Nancy told the inquest: ‘Ellame had concluded that professionals did not want to help her, she felt ignored and unsupported.’
After attempting suicide once again, she was eventually admitted to the Bluefin ward – a children’s acute ward – at Worthing Hospital.
A few days later, she was detained under Mental Health Act after absconding – but there were no specialist beds available and she remained on the children’s ward, under 24-hour one-to-one observation by a registered mental health nurse.
The inquest heard that Ellame had complained to her father that she had woken in the night after nightmares to find no one there.
He visited her on March 22 and the pair spent a few hours laughing and joking with each other, the hearing was told – but later that evening her parents became concerned as they Ellame had not read a WhatsApp message sent to her.
Nancy Ford-Dunn called the hospital and was told Ellame had absconded between 10 to 15 minutes earlier and officials were calling police.
Ahead of her death, Ellame had absconded ‘multiple times’ during her stay on Bluefin ward at Worthing Hospital, which was not a specialist mental health ward
A jury at the inquest in Horsham, West Sussex, heard Ellame had enjoyed primary school but began to struggle when she went to secondary school in 2016
Mr Ford-Dunn jumped into his car and went to search the nearby beach and train station before seeing police cars heading for the hospital.
When he got here he was told his daughter had been found in a ‘critical condition’ in the hospital grounds. Despite resuscitation attempts she was later pronounced dead.
Ellame’s mental health care was provided by Sussex Partnership NHS Foundation Trust (SPFT) while Bluefin Ward was run by University Hospitals Sussex NHS Foundation Trust (UHST).
The inquest was told there was no jointly agreed plan for Ellame between the two trusts while she was an inpatient on the Bluefin ward in February and March 2022.
Agency nursing staff did not have access to records and did not know whether a patient should be followed out of the ward or not, it was heard.
The jury concluded Ellame’s death was contributed to by a shortage of acute mental health beds both in Sussex and nationally.
The jury also concluded it was ‘inappropriate’ for Ellame to have been detained on a paediatric ward.
It said there was a lack of security on the ward to prevent her absconding and the risk assessments in place were inadequate.
Ellame’s inquest was told there was no jointly agreed plan for her between two NHS trusts while she was an inpatient on Worthing Hospital’s Bluefin ward in February and March 2022
In the narrative conclusion, the jury said: ‘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.’
The jury also ruled there was inconsistency in nursing handovers and little guidance on how to respond if Ellame should abscond.
They said: ‘It is not known if Ellame had intended to take her life on the 20 March 2022.’
Mrs Ford-Dunn said she felt Ellame had been ‘failed’ by mental health services and the family had felt unsupported.
Nina Marshall of the Sussex NHS Partnership Trust said waiting times for children and adolescents for a mental health bed had dropped from 26 days in 2021-2022 to about eight days this year.
But Joanne Andrews, area coroner for West Sussex, said she would be writing a Prevention of Future Deaths report to NHS England over the lack of acute beds for children and adolescents.
She also also asked UH Sussex and SPFT to provide evidence of what improvements and changes made, as she decided whether to write a similar PFD report.
UHST was fined £200,000 last November after admitting failing to provide safe care and treatment to Ellame which exposed her to a significant risk of ‘avoidable harm’.
Ellame was ‘failed’ by mental health services and her family felt unsupported, her mother Nancy Ford-Dunn has said
Dr Maggie Davies, chief nurse for University Hospitals Sussex NHS Foundation Trust, said after the inquest: ‘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.
‘As the inquest heard, everyone accepts that general hospital wards are not the right place for young people suffering acute mental distress.
‘However, while vulnerable patients like Ellame remain with us, we have a duty to keep them safe for as long as it takes for the right care to become available elsewhere.’
She said the trust had since ‘fundamentally improved the way we care for patients with mental health needs within our hospitals, including additional staff training and stronger security protocols’.
She added: ‘We remain committed to working with our NHS partners to find better ways of caring for patients who need specialist care away from general hospital wards.’
Dr Richard Sankar, clinical director for the NHS-led Hampshire, Isle of Wight, Sussex, Kent and Medway Child and Adolescent Mental Health Services (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.’
For confidential support, call Samaritans on 116 123, visit samaritans.org or visit the calmzone.net/get-support.
The parents of a teenage girl who took her own life have condemned ‘devastating failures’ by NHS mental health services which were exposed at her inquest.
Ellame Ford-Dunn, 16, from Upper Beeding in West Sussex, died after ‘inadequate’ care, ‘poor communication’ and how no ‘suitable’ bed could be found, a jury said.
She had absconded ‘multiple times’ during her stay on Bluefin ward at Worthing Hospital, which was not a specialist mental health ward.
The student had been in and out of mental health facilities for several years before finally being discharged home – but was then admitted to hospital in February 2022 after repeatedly self-harming, having also suffered with an eating disorder.
She was placed in a children’s medical ward but was later detained under the Mental Health Act after absconding and attempting to kill herself, being placed under 24-hour one-to-one observation by an agency-provided registered mental health nurse.
On March 20 2022, Ellame told an agency nurse she needed to go to the toilet, before breaking into a run out of Worthing Hospital.
A search of the grounds was launched before Ellame was discovered an hour after she absconded, lying in bushes in the hospital grounds and – despite attempts to save her – she was pronounced dead shortly afterwards.
Her parents Ken and Nancy Ford-Dunn have told how the family was left ‘devastated’ by Ellame’s death – and called for urgent action to give children with mental health issues the care they need.
Ellame Ford-Dunn, 16, from Upper Beeding in West Sussex, took her own life after absconding from Worthing Hospital in West Sussex in March 2022
Her parents Ken and Nancy Ford-Dunn have called for urgent action to give children with mental health issues the care they need
Fighting back tears, her parents said ‘devastating failures’ to provide care for their daughter as well as inadequate training and communication had cost Ellame her life.
Mrs Ford-Dunn said: ‘I can’t brush her hair and paint her nails and wash her clothes. I can’t deal those parenting things that I want to be able to do and so all we’ve got left is this fight – to make sure that everybody understands how badly she was failed.
‘It’s devastating. It’s hard to explain, because you have the devastation you have – it’s overwhelming.’
Mr Ford-Dunn said he had been driven by anger to hold the hospital trusts to account that he felt he had not had time to grieve.
They said there was a lack of co-ordinated care between social services, the hospital trust and specialist mental health services.
The jury at the inquest in Horsham, West Sussex, heard Ellame had enjoyed primary school but began to struggle when she went to secondary school in 2016.
She suffered from severe stress and would often self-harm as her mental health deteriorated.
The hearing was told her parents had difficulty getting her to go to school and despite seeking help they felt there was very little help from medical services.
The student had been in and out of mental health facilities for several years before being discharged home – but was then admitted to hospital in February 2022 after self-harming
As her mental health continued to decline, Ellame, who had ADHD and autism, continued to self-harm and twice tried to take her own life in 2019.
At the start of the Covid-19 pandemic in 2020, she began refusing to eat and was later diagnosed as anorexic.
She was under the care of Child and Adult Mental Health Services (CAMHS) and spent over 18 months in inpatient mental health care units.
in 2021 the teenager confided in her parents that she had been the victim of sexual abuse.
After a spell in the Priory Hospital in Manchester, she was discharged into the care of Chalkhill Hospital, run by the Sussex Partnership NHS Foundation Trust.
She spent several months at the hospital receiving treatment to tackle her self-harming and anorexia.
Ellame’s condition was considered to have improved to such a level that she was discharged from Chalkhill Hospital in January 2022.
As well as a care plan, she was also assigned a paediatric psychiatrist and an initial meeting between them appeared to go well.
Ellame, who had ADHD and autism, twice tried to take her own life in 2019 – and at the start of the pandemic in 2020, she began refusing to eat and was later diagnosed as anorexic
However, the inquest heard that once back at home Ellame’s condition deteriorated rapidly and she began to self-harm and attempted suicide more than once.
She was repeatedly taken to hospital after self-harming but was discharged after treatment several times.
Her mother Nancy told the inquest: ‘Ellame had concluded that professionals did not want to help her, she felt ignored and unsupported.’
After attempting suicide once again, she was eventually admitted to the Bluefin ward – a children’s acute ward – at Worthing Hospital.
A few days later, she was detained under Mental Health Act after absconding – but there were no specialist beds available and she remained on the children’s ward, under 24-hour one-to-one observation by a registered mental health nurse.
The inquest heard that Ellame had complained to her father that she had woken in the night after nightmares to find no one there.
He visited her on March 22 and the pair spent a few hours laughing and joking with each other, the hearing was told – but later that evening her parents became concerned as they Ellame had not read a WhatsApp message sent to her.
Nancy Ford-Dunn called the hospital and was told Ellame had absconded between 10 to 15 minutes earlier and officials were calling police.
Ahead of her death, Ellame had absconded ‘multiple times’ during her stay on Bluefin ward at Worthing Hospital, which was not a specialist mental health ward
A jury at the inquest in Horsham, West Sussex, heard Ellame had enjoyed primary school but began to struggle when she went to secondary school in 2016
Mr Ford-Dunn jumped into his car and went to search the nearby beach and train station before seeing police cars heading for the hospital.
When he got here he was told his daughter had been found in a ‘critical condition’ in the hospital grounds. Despite resuscitation attempts she was later pronounced dead.
Ellame’s mental health care was provided by Sussex Partnership NHS Foundation Trust (SPFT) while Bluefin Ward was run by University Hospitals Sussex NHS Foundation Trust (UHST).
The inquest was told there was no jointly agreed plan for Ellame between the two trusts while she was an inpatient on the Bluefin ward in February and March 2022.
Agency nursing staff did not have access to records and did not know whether a patient should be followed out of the ward or not, it was heard.
The jury concluded Ellame’s death was contributed to by a shortage of acute mental health beds both in Sussex and nationally.
The jury also concluded it was ‘inappropriate’ for Ellame to have been detained on a paediatric ward.
It said there was a lack of security on the ward to prevent her absconding and the risk assessments in place were inadequate.
Ellame’s inquest was told there was no jointly agreed plan for her between two NHS trusts while she was an inpatient on Worthing Hospital’s Bluefin ward in February and March 2022
In the narrative conclusion, the jury said: ‘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.’
The jury also ruled there was inconsistency in nursing handovers and little guidance on how to respond if Ellame should abscond.
They said: ‘It is not known if Ellame had intended to take her life on the 20 March 2022.’
Mrs Ford-Dunn said she felt Ellame had been ‘failed’ by mental health services and the family had felt unsupported.
Nina Marshall of the Sussex NHS Partnership Trust said waiting times for children and adolescents for a mental health bed had dropped from 26 days in 2021-2022 to about eight days this year.
But Joanne Andrews, area coroner for West Sussex, said she would be writing a Prevention of Future Deaths report to NHS England over the lack of acute beds for children and adolescents.
She also also asked UH Sussex and SPFT to provide evidence of what improvements and changes made, as she decided whether to write a similar PFD report.
UHST was fined £200,000 last November after admitting failing to provide safe care and treatment to Ellame which exposed her to a significant risk of ‘avoidable harm’.
Ellame was ‘failed’ by mental health services and her family felt unsupported, her mother Nancy Ford-Dunn has said
Dr Maggie Davies, chief nurse for University Hospitals Sussex NHS Foundation Trust, said after the inquest: ‘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.
‘As the inquest heard, everyone accepts that general hospital wards are not the right place for young people suffering acute mental distress.
‘However, while vulnerable patients like Ellame remain with us, we have a duty to keep them safe for as long as it takes for the right care to become available elsewhere.’
She said the trust had since ‘fundamentally improved the way we care for patients with mental health needs within our hospitals, including additional staff training and stronger security protocols’.
She added: ‘We remain committed to working with our NHS partners to find better ways of caring for patients who need specialist care away from general hospital wards.’
Dr Richard Sankar, clinical director for the NHS-led Hampshire, Isle of Wight, Sussex, Kent and Medway Child and Adolescent Mental Health Services (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.’
For confidential support, call Samaritans on 116 123, visit samaritans.org or visit the calmzone.net/get-support.
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