Key Highlights
- They found “inadequate provision” of mental health beds also contributed to her death. 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. Ellame’s parents, Ken and Nancy Ford-Dunn, urged the government to increase funding for mental health services to ensure “other families don’t have to experience the worst thing imaginable”. 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. Support new mothers with mental ill health | LetterRead moreUniversity hospitals Sussex (UHSussex), which runs the acute ward, was fined £200,000 last year in a separate prosecution over Ellame’s death. Her mental health care was provided by Sussex partnership NHS foundation trust (SPFT).
- Jurors concluded that “poor coordination, communication and accountability” between “multiple agencies” also contributed to Ellame’s death.“Inconsistency in nursing handovers” and a lack of guidance for staff were another factor in her death, they found. The jury foreman said: “The 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.“UHSussex’s 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.”In a statement Ellame’s parents said the devastation of their daughter’s death would be “compounded if no lessons are learnt and no meaningful changes are made, as so often has been the case”. They added: “We therefore call on NHS England and Wes Streeting to increase funding for mental health services so that more young people aren’t left waiting for the care that they so desperately need.“We 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.”Jodie Anderson, a senior caseworker at the charity Inquest, which has supported the family, said: “Ellame’s inquest has exposed a mental health system in Sussex that is crumbling at the seams.“A lack of specialist beds and a dismissive response to Ellame’s distress left her to languish in an unsuitable paediatric ward.
- A lack of urgency and professional curiosity was endemic throughout her care.”The family lawyer, Ilaria Minucci of Birnberg Peirce, said: “Ellame’s case needs to remind us that stories like hers are not isolated instances, and th.
