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.<\/p>\n
Ellame Ford-Dunn, 16, who had a history of self-harm, died in March 2022 after absconding from an acute children\u2019s ward where she had been put because of a dearth of appropriate mental health beds.<\/p>\n
Her family and campaigners say Ellame\u2019s death exposed a mental health system \u201ccrumbling at the seams\u201d.<\/p>\n
The inquest jury at West Sussex<\/a> coroner\u2019s court was told that Ellame absconded \u201cmultiple times\u201d during her stay at Worthing hospital\u2019s Bluefin ward, which was not a specialist mental health unit.<\/p>\n Jurors concluded the decision to place Ellame there was \u201cinappropriate\u201d and \u201cmore than minimally\u201d contributed to her death. They found \u201cinadequate provision\u201d of mental health beds also contributed to her death.<\/p>\n 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.<\/p>\n Ellame\u2019s parents, Ken and Nancy Ford-Dunn, urged the government to increase funding for mental health services to ensure \u201cother families don\u2019t have to experience the worst thing imaginable\u201d.<\/p>\n 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.<\/p>\n University hospitals Sussex (UHSussex), which runs the acute ward, was fined \u00a3200,000 last year<\/a> in a separate prosecution over Ellame\u2019s death.<\/p>\n Her mental health care was provided by Sussex partnership NHS<\/a> foundation trust (SPFT). Jurors concluded that \u201cpoor coordination, communication and accountability\u201d between \u201cmultiple agencies\u201d also contributed to Ellame\u2019s death.<\/p>\n \u201cInconsistency in nursing handovers\u201d and a lack of guidance for staff were another factor in her death, they found.<\/p>\n The jury foreman said: \u201cThe 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.<\/p>\n \u201cUHSussex\u2019s policy for missing patients was not designed for high-risk mental health patients, and the procedure to be followed in the event of absconsion was unclear and not appropriately communicated.\u201d<\/p>\n In a statement Ellame\u2019s parents said the devastation of their daughter\u2019s death would be \u201ccompounded if no lessons are learnt and no meaningful changes are made, as so often has been the case\u201d.<\/p>\n They added: \u201cWe therefore call on NHS England and Wes Streeting to increase funding for mental health services so that more young people aren\u2019t left waiting for the care that they so desperately need.<\/p>\n \u201cWe call on SPFT to create effective specialist provision for young people with mental health needs who are currently still inappropriately placed, like Ellame was, on local paediatric wards that are not set up to provide safe and positive mental health care.\u201d<\/p>\n Jodie Anderson, a senior caseworker at the charity Inquest, which has supported the family, said: \u201cEllame\u2019s inquest has exposed a mental health system in Sussex that is crumbling at the seams.<\/p>\n \u201cA lack of specialist beds and a dismissive response to Ellame\u2019s distress left her to languish in an unsuitable paediatric ward. A lack of urgency and professional curiosity was endemic throughout her care.\u201d<\/p>\n The family lawyer, Ilaria Minucci of Birnberg Peirce, said: \u201cEllame\u2019s case needs to remind us that stories like hers are not isolated instances, and that they reflect a crisis at the national level in respect of children\u2019s mental health services that needs to be dealt with urgently.\u201d<\/p>\n In the UK and Ireland, Samaritans<\/a> can be contacted on freephone 116 123, or email jo@samaritans.org<\/a> or jo@samaritans.ie<\/a>. In the US, you can call or text the 988 Suicide & Crisis Lifeline<\/a> at 988 or chat at 988lifeline.org<\/a>. In Australia, the crisis support service Lifeline<\/a> is 13 11 14. Other international helplines can be found at befrienders.org<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"A shortage of mental health beds and poor communication between agencies contributed to the death of a teenage…\n","protected":false},"author":2,"featured_media":277258,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35],"tags":[103,61,60,410,411],"class_list":{"0":"post-277257","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-mental-health","8":"tag-health","9":"tag-ie","10":"tag-ireland","11":"tag-mental-health","12":"tag-mentalhealth"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/277257","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/comments?post=277257"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/277257\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media\/277258"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media?parent=277257"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/categories?post=277257"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/tags?post=277257"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}