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Mental health bed shortages contributed to teenager's death, inquest finds
Summary
An inquest concluded that a shortage of specialist mental health beds and poor communication between agencies contributed to the death of 16-year-old Ellame Ford‑Dunn after she absconded from an acute paediatric ward in March 2022; the coroner said she will issue a prevention of future deaths report.
Content
An inquest has concluded into the death of 16-year-old Ellame Ford‑Dunn, who died in March 2022 after leaving an acute paediatric ward where she had been placed because a specialist mental health bed was not available. Jurors found that the decision to place her on a non-specialist ward was inappropriate and that weaknesses in coordination and communication between agencies were contributing factors. The coroner, Joanne Andrews, announced she will issue a prevention of future deaths report. The inquest followed an earlier prosecution that resulted in a fine for the hospital trust involved.
Key findings:
- The inquest concluded a shortage of specialist mental health beds and poor coordination between agencies contributed to Ellame's death.
- Officials reported Ellame absconded from an acute paediatric ward in March 2022 and later died on hospital grounds.
- The coroner said she will issue a prevention of future deaths report to highlight risks to other children.
- University Hospitals Sussex was fined in a separate prosecution related to the case last year.
Summary:
The jury linked the lack of appropriate specialist beds and failings in inter-agency communication to the circumstances of Ellame Ford‑Dunn's death, and the coroner will prepare a formal prevention report. Undetermined at this time.
