Lack of mental health beds contributed to UK teenager's death, inquest finds

"A shortage of mental health beds and poor communication between agencies contributed to the death of a teenage girl on hospital grounds, an inquest has found. Ellame Ford-Dunn, 16, who had a history of self-harm, died in March 2022 after absconding from an acute children's ward where she had been put because of a dearth of appropriate mental health beds."

"Jurors concluded the decision to place Ellame there was inappropriate and more than minimally contributed to her death. They found inadequate provision of mental health beds also contributed to her death. The coroner Joanne Andrews said she would issue a prevention of future deaths report to warn that more children would die unless the inadequate provision of mental health beds was tackled."

"When Ellame absconded she was not immediately followed by staff, because they were not allowed to chase patients out of the ward, the inquest heard. It took 59 minutes for her to be found by police, the jury was told. University hospitals Sussex (UHSussex), which runs the acute ward, was fined 200,000 last year in a separate prosecution over Ellame's death."

Ellame Ford-Dunn, aged 16 with a history of self-harm, died in March 2022 after absconding from Worthing hospital's Bluefin ward, a non-specialist acute children's unit used because of a shortage of appropriate mental health beds. Jurors found that placing her on that ward was inappropriate and that inadequate provision of mental health beds contributed to her death. Staff did not immediately follow her when she left because policy barred chasing patients, and police located her 59 minutes later. Jurors also identified poor coordination and communication between agencies, inconsistent nursing handovers, and lack of staff guidance as contributing factors. A prevention of future deaths report will be issued.

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