At-risk teenager died after absconding from paediatric ward which had no security
On 2 February 2026, an inquest jury in Horsham found that multiple failings in mental health care contributed to the death of 16-year-old Ellame Ford-Dunn on 20 March 2022. Ellame was autistic and had PTSD. She was detained under the Mental Health Act in an acute paediatric ward at Worthing Hospital – a placement the jury described as “inappropriate” – while she awaited a specialist Tier 4 mental health bed. Worthing Hospital is run by the University Hospitals Sussex NHS Foundation Trust (“UHSx Trust”).
Ellame had been in the hospital since 28 February 2022 and was cared for by a series of agency mental health nurses who did not have access to the mental health risk assessments developed by the Sussex Partnership NHS Foundation Trust (the mental health Trust) or UHSx Trust’s care notes or incident reports which were all held digitally.
Any person wishing to exit the ward could do so straightforwardly by pressing a button by the door. The ward arranged no extra security for Ellame, despite assessing her as being at high risk of absconding, self-harm and suicide. On 8 March 2022, Ellame absconded and nearly died by hurting herself in the grounds of the hospital. The hospital made no changes to her care after this very serious incident. On 20 March 2022, Ellame again escaped from the ward, self-harmed in the grounds of the hospital, and very sadly was found dead an hour later.
A jury found that the following factors contributed to Ellame’s death:
- Inadequate provision of Tier 4 beds for children with severe mental health difficulties in Sussex and nationally.
- The decision to detain Ellame on an acute paediatric ward without the provision of security.
- The inconsistency of nursing handovers and little guidance on how to plan or respond if risk escalated or if Ellame absconded.
- Poor co-ordination, communication and accountability between multiple agencies providing care for Ellame.
The jury also found that the UHSx Trust’s policy for missing patients was not designed for high-risk mental health patients and the procedure to be followed in the event of absconding was unclear and not appropriately communicated.
In November 2024, UHSx Trust pleaded guilty to failing to provide safe care and treatment to Ellame which exposed her to a significant risk of avoidable harm. The Trust was fined £200,000.
Area Coroner Joanne Andrews will issue a Prevention of Future Deaths report to NHS England concerning the use of acute paediatric wards for children and young people requiring specialist psychiatric support.
Oliver Lewis of Doughty Street Chambers represented the family, instructed by Ilaria Minucci of Birnberg Peirce. They were supported by INQUEST Senior Caseworker Jodie Anderson.
Other Interested Persons at the inquest were Sussex Partnership NHS Foundation Trust, University Hospitals Sussex NHS Foundation Trust, a Registered Mental Health Nurse, West Sussex County Council, NHS Sussex Integrated Care Board and the Care Quality Commission.
The inquest was reported by the BBC, The Guardian, Daily Mail, The Mirror, The Telegraph and The Argus.
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
