On Monday, a jury inquest at West Sussex Coroner’s Court in Horsham found “inadequate” provision of care contributed to the death of Ellame when she absconded from her ward at Worthing Hospital and ligatured in the grounds.
Sussex Partnership NHS Foundation Trust (SPFT) was the primary care provider for Ellame but did not have an “appropriate” bed available for her on a mental health ward when she was sectioned in March 2022.
SPFT, which specialised in mental health and learning disabilities, was ranked 59th of 61 non-acute trusts across the UK in data published by the Department for Health and Social Care last year.
Ellame Ford-Dunn (Image: Family handout)
A group of families who say their loved ones died by suicide after “failings in care from SPFT” were “not surprised” when SPFT received that rating.
Some of them have attended Ellame’s inquest to support her family and listen as “similar themes” to their loved ones’ inquests were brought up.
Shelagh Sheldrick, mother of Matty Sheldrick, 29, who left A&E and hanged themselves in the grounds of Royal Sussex County Hospital in Brighton on November 22, 2022, said she felt “compelled” to attend Ellame’s inquest.
Matty Sheldrick and dog Lola (Image: The Sheldrick family)
Ms Sheldrick said her child “felt unwanted, othered and rejected” by healthcare services after presenting in hospital in September 2022.
Last week, she explained: “My motivation for attending the inquest was to quietly show up for the family to offer support and compassion in a situation where faith in humanity is often lost.
“Matty’s ambition was to be in a supporting role to help others. I feel the baton has been passed to me now on his behalf.”
Ms Sheldrick added that although Ellame was younger than Matty and died before Matty did, the “chaos” and the “culture” that appeared to surround their healthcare experiences seemed similar.
“How can you not see the pattern?” she asked.
Morgan Betchley, 19, was the mother of a one-year-old boy when she died through a self-inflicted injury on an SPFT-run ward at Meadowfield Hospital in Worthing on March 9, 2023.
Meadowfield Hospital in Worthing (Image: The Argus)
At her inquest in November 2024, jurors concluded that evidence showed “repeated failures to follow policies and procedures” by staff at Meadowfield.
Morgan’s mother-in-law Louise Hodgson says SPFT has a lack of “compassion” and “understanding” of the “depth of what’s wrong” at the trust.
Morgan’s mother, Tanya Betchley, wanted to be at the inquest into Ellame’s death because “her loss is in such similar circumstances” to Morgan’s.
She said: “The process of inquest is brutal and it would have been impossible for me to be strong enough to be a support as it brings all the horror back so vividly.
“It’s even harder to know that the jury findings are always so similar, time and again, yet nothing is learned and these tragedies keep happening.
“I really hope that this time things are different for Nancy, Ken and all the family, we will keep supporting them as their pain doesn’t end here.”
Ellame was put on an acute paediatric ward because there were no spaces for her on a mental health ward, and a “number” of young people are currently in a similar boat not just in Sussex but across the UK, the inquest heard.
Her mother, Nancy Ford-Dunn said: “For us to have heard in court there are still so many children stuck in that situation is abhorrent, actually, because we’ve lived that.
Mum Nancy and dad Ken outside Brighton Magistrates’ Court today (Image: The Argus)
“We’ve seen the results of that, and to know that there are other people suffering like we suffered while we were waiting for Ellame to get a bed.
“After all these years – it’s been nearly four years – and those changes haven’t been made.”
Dr Oliver Dale, chief medical officer, Sussex Partnership NHS Foundation Trust, said: “We have a responsibility to keep people safe whilst under our care. If we haven’t done this, our responsibility is to understand what happened.
“This involves working with our partners, families and carers to improve. We will always strive to achieve this.
“We also need to keep working on how we support families. That includes listening to feedback, especially when people’s experience has been poor.
“We are sorry for where this has been the case. We are absolutely committed to improving and making sure that families are supported more consistently.”
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