Overview
- Jurors found inadequate provision of specialist mental health beds and poor multi-agency communication more than minimally contributed to the death of 16-year-old Ellame Ford-Dunn.
- Her detention on Bluefin, an acute paediatric ward, was ruled inappropriate, with risk assessments deemed inadequate and applied inconsistently.
- When she absconded on 20 March 2022, staff did not immediately follow; police found her 59 minutes later, and the lack of security provision was judged contributory.
- The coroner requested evidence from University Hospitals Sussex and Sussex Partnership on improvements to record access, handovers and report sharing.
- University Hospitals Sussex was fined £200,000 in November after admitting failures, and both trusts issued apologies and pledged improvements as other families raised similar concerns about Sussex Partnership.