A family is facing deep sorrow after the tragic loss of their teenage daughter on the premises of a hospital.

Ellame Ford-Dunn tragically took her own life in March 2022 after absconding from the Bluefin pediatric ward at Worthing Hospital, where she was receiving mental health treatment as an inpatient.

The 16-year-old made multiple attempts to run away while on the Bluefin ward at Worthing Hospital, which was not specifically designated as a mental health facility.

Expressing her devastation, Ellame’s mother, Nancy Ford-Dunn, lamented the inability to perform everyday parental tasks for her daughter, emphasizing the urgent need for awareness about the failures that led to her demise.

An inquiry determined that it was inappropriate to confine Ellame to a pediatric ward from February 28 to March 20, 2022, citing insufficient and inconsistently applied risk assessments.

Upon Ellame’s escape from the ward on March 20, staff did not promptly pursue her, resulting in a 59-minute delay before she was located by the authorities.

The decision to retain Ellame on the ward without adequate security measures was also identified as a contributing factor to her death. She was placed in Bluefin, an acute pediatric ward, due to the lack of specialized mental health beds.

Her mental health care was overseen by Sussex Partnership NHS Foundation Trust (SPFT), while Bluefin Ward was managed by University Hospitals Sussex NHS Foundation Trust (UHST).

The jury concluded that inadequate coordination, communication, and accountability among multiple agencies played a role in Ellame’s tragic outcome. They highlighted inconsistencies in nursing handovers and the absence of clear guidance for staff as additional contributing factors.

Ellame’s mother expressed dissatisfaction with the support provided by social services and healthcare professionals, noting her daughter’s mental health struggles dating back to her time in secondary school.

Ellame had been previously hospitalized for mental health reasons but was discharged in January 2022 to live with her parents.

Following UHST’s admission of failing to ensure Ellame’s safety, resulting in a significant risk of harm, the trust was fined £200,000 in November last year.

UHST claimed significant improvements in their care services post-Ellame’s tragic passing, acknowledging the need for better protection of vulnerable individuals under their care.

Dr. Maggie Davies, UHST’s chief nurse, expressed deep regret over the failure to safeguard Ellame during her stay at the facility.

Dr. Richard Sankar, clinical director for the NHS-led regional mental health services, extended condolences to Ellame’s family and acknowledged the delay in securing a mental health bed for her.

The coroner has initiated a report on preventing future deaths from NHS England following revelations that numerous young individuals are still housed in acute pediatric wards while awaiting placement in specialized mental health facilities.

Moreover, the coroner has requested both trusts to submit evidence of improvements in their communication and information-sharing systems to prevent similar incidents in the future.