Shortage of Mental Health Beds and Poor Communication Linked to Teen’s Death

West Sussex, UK – A shortage of mental health beds and poor communication between agencies contributed to the death of 16-year-old Ellame Ford-Dunn, an inquest has concluded.

Ellame, who had a history of self-harm, died in March 2022 after absconding from Worthing Hospital’s Bluefin ward, an acute children’s unit not equipped for mental health care. Her family and campaigners say her death exposed a mental health system “crumbling at the seams.”

The inquest at West Sussex Coroner’s Court heard that Ellame absconded multiple times during her stay. Jurors found placing her on the ward “inappropriate” and said the lack of specialist mental health beds “more than minimally” contributed to her death.

Coroner Joanne Andrews announced she would issue a Prevention of Future Deaths report, warning that more children could die unless the shortage of mental health beds is addressed.

Ellame’s parents, Ken and Nancy Ford-Dunn, urged the government to increase funding for mental health services, saying, “Other families should not have to experience the worst thing imaginable.”

The inquest revealed staff did not immediately follow Ellame when she absconded due to hospital policies, and it took 59 minutes for police to locate her. University Hospitals Sussex (UHSussex), which runs the ward, was previously fined £200,000 over Ellame’s death.

Jurors highlighted “poor coordination, communication, and accountability” between multiple agencies, inconsistencies in nursing handovers, and unclear procedures for missing high-risk mental health patients.

Supporters and lawyers say Ellame’s death reflects a wider national crisis in children’s mental health care. Jodie Anderson of charity Inquest said, “A lack of specialist beds and a dismissive response to Ellame’s distress left her in an unsuitable ward.”

The family’s lawyer, Ilaria Minucci, added, “Ellame’s case is not isolated. It underlines an urgent national crisis in children’s mental health services.”