Ellame Ford-Dunn, 16, died after ligaturing in the grounds of Worthing Hospital while she was a mental health inpatient on March 20, 2022.
The teenager, who had autism, ADHD and an eating disorder, absconded from the Bluefin ward, an acute paediatric ward, and ran into the grounds of the hospital without being followed by staff.
University Hospitals Sussex NHS Foundation Trust pleaded guilty to failing to provide safe care and treatment to Ellame which exposed her to a significant risk of “avoidable harm” at a hearing at Brighton Magistrates’ Court on October 27.
The trust was fined £200,000 plus legal costs at the same court in November.
Today, January 26, the inquest into Ellame’s death resumed at West Sussex Coroner’s Court in Horsham following criminal proceedings against the trust.
A video was shown to the court in which the 16-year-old was described by her family as a “sweet delightful girl who deserved to have the life of fun she so desperately wanted to get well for”.
Her family said in the video: “She always wanted to be where the laughter was. Everyone loved Ellame.
“She had a kind heart. She was where the fun was at.
“She expressed herself through art, poetry and dance, all of which she had such a talent for.
“There were dark times for all of us as she struggled so severely with her mental health.”
Ellame’s parents, Nancy and Ken Ford-Dunn, gave evidence to the court, stating they first became concerned about Ellame’s mental health when she started secondary school in 2016.
Mrs Ford-Dunn said Ellame’s mental health “significantly declined in 2018” and her daughter struggled during the Covid lockdown in 2020.
“Home life was awful,” Mrs Ford-Dunn said, “Ken and I witnessed her decline.”
They said they hope the inquest brings “some answers and accountability” as well as “change for other children”.
Ellame was taken to hospital several times due to incidents of self harm.
She also had a history of absconding from hospital.
Mrs Ford-Dunn said she requested help from social services to keep Ellame safe when she was at home and was reportedly told she needed to “use her family network”.
Mrs Ford-Dunn said the family requested “support with management at home”, but felt they were “not given answers and commitments”.
At the end of February, Mrs Ford-Dunn said she asked the hospital to admit her daughter as they “could not cope anymore”.
Ellame was admitted to the Bluefin ward at Worthing Hospital for the final time on February 28 and was detained under Section 3 of the Mental Health Act on March 12.
Ellame’s father described the last time he saw Ellame on the afternoon of March 20, 2022.
Mr Ford-Dunn visited Ellame at around 2.15pm on the day of her death. He arrived at the ward to find her asleep and was told by a healthcare assistant that she had had a “difficult morning”.
When Ellame awoke around an hour later, she told Mr Ford-Dunn she had awoken in the night following a nightmare to find there was no one in her room, despite her being under 24/7 observation, he said.
She said she then left her room and ligatured, before she was found by hospital staff.
Mr Ford-Dunn said he and his daughter “chatted in the same way [they] usually did” before he left at around 5.30pm.
At around 8pm, Mrs Ford-Dunn called the Bluefin ward as Ellame was not reading her messages. She was told her daughter had absconded ten to 15 minutes earlier, the court heard.
Mr Ford-Dunn said he left to drive back to the hospital and the parents were told Ellame was alive but in a critical condition.
Later that evening, Mr Ford-Dunn was told at the hospital that Ellame had died.
“Everything became blurry,” he said.
“It felt like everything was in slow motion. I remember shouting ‘no’ and I had a meltdown.
“Nothing felt real. I felt at a loss. I did not know what was going on or what I should do.”
Consultant child psychiatrist Doctor Arianna Marconi gave evidence regarding her care of Ellame after she was discharged from Chalkhill Hospital, Haywards Heath, in January 2022.
She was allocated to Ellame on January 19, the day after she was discharged from hospital, and met her for the first time on February 1.
Doctor Marconi said she was “aware of the risk to herself” as she was “known to self harm”, was “restricting her food” and had a history of absconding.
Ellame was put on a care plan, the court heard, which included support from Aspens, a specialist autism charity, and therapy.
When questioned by area coroner Joanne Andrews on mitigating Ellame’s risk to herself in the community, Doctor Marconi said: “She wanted to be discharged, she wanted to be at home.
“We were mitigating risk and trying to come up with a plan to mitigate.”
The court heard there were several incidents involving A&E attendance following Ellame’s first meeting with Doctor Marconi and prior to her readmission.
“We were concerned,” Doctor Marconi said.
“The food restriction became more and more intense. The symptoms were getting worse.”
Oliver Lewis, representing Ellame’s parents, asked Doctor Marconi if any changes were made at the hospital to ensure she could not leave when she was readmitted, such as a security guard.
Doctor Marconi said “as far as [she] was aware, no”. Mr Lewis also asked if Ellame saw a psychiatrist between March 12 and 20, to which she answered “no”.
A representative for University Hospitals Sussex NHS Foundation Trust said “in an ideal world, Ellame would not have been an inpatient at Bluefin” and she was there because “there was no mental health bed for her”.
The inquest into the death of Ellame Ford-Dunn at West Sussex Coroner’s Court continues.
For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.
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