On March 20, 2022, tragedy struck at Worthing Hospital in West Sussex when 16-year-old Ellame Ford-Dunn, a vulnerable teenager with complex mental health needs, absconded from her ward and died after being found ligatured in the hospital grounds. The incident, which has since sparked national debate over the adequacy of mental health care for young people, culminated this week in a landmark court ruling that saw University Hospitals Sussex NHS Foundation Trust fined £200,000 for failing to provide safe care and treatment.
Ellame, described by her father as a "bright firework in the dark sky" and a "loving caring soul," had been under 24-hour one-to-one observation by a registered mental health nurse at Worthing Hospital. According to the BBC, she was admitted not because the ward was suitable for her, but because "no adequate bed" for her risk level was available anywhere else in the country. The court heard that the trust was placed in an impossible position, with national shortages of specialist "tier four" beds for children with acute mental health needs—an issue that is sadly all too common in the UK.
Ellame had a long and complicated history of trauma, self-harm, autism, ADHD, and an eating disorder. She was under the care of Child and Adolescent Mental Health Services (CAMHS) and had spent more than 18 months in inpatient mental health care units, according to the charity Inquest. After being discharged from Chalkhill Hospital (the only children’s inpatient psychiatric unit in Sussex) in January 2022, she was readmitted to Worthing Hospital’s Bluefin Ward at the end of February following another episode of self-harm. Just days later, she was detained under section 3 of the Mental Health Act after absconding and ligaturing, prompting the hospital to place her under constant one-to-one supervision.
Despite these precautions, on the evening of March 20, Ellame managed to leave the ward. Security staff searched the hospital grounds before eventually calling Sussex police. An hour later, officers found Ellame ligatured in the hospital grounds. She was rushed back inside but was declared dead shortly after. The hospital’s own policy at the time prevented staff from following patients who left the ward, a procedure that District Judge Tessa Szagun later described as a critical failure that put Ellame at serious risk.
At the sentencing on November 26, 2025, at Brighton Magistrates’ Court, the trust pleaded guilty to failing to provide safe care and treatment, exposing Ellame to a significant risk of avoidable harm. The judge ordered the trust to pay £200,000 to the Care Quality Commission (CQC), as well as prosecution costs of £25,405.70 and a victim surcharge of £190. In her remarks, Judge Szagun was unequivocal: "Clear instructions to follow Ellame if she left the ward should have been incorporated into the care plan." The judge went on to say, "Nothing that the defendant organisation expressed in terms of their heartfelt apology and condolence or regret at the consequences of their accepted omissions, nor any fine I impose, or indeed any sentencing remarks I make, can begin to make any difference to how her family have been impacted by the devastation and shock of this loss."
The court also heard how the trust had been forced to admit Ellame to an acute ward because no specialist beds were available—a situation described by prosecutor James Marsland as a "national issue." The prosecution acknowledged the trust’s difficult position, noting that turning Ellame away would have left her with nowhere to go. Nonetheless, the trust’s longstanding policy of not allowing staff to follow patients off the ward was found to be a direct factor in Ellame’s death. This same issue had arisen previously in the case of Patricia Genders, another vulnerable patient who died after leaving a hospital run by the same trust.
Outside the court, Ellame’s father, Ken Ford-Dunn, spoke with raw emotion about his family’s loss. "The loss of Ellame has been devastating to all who loved her. There’s no greater heartbreak than losing a child. But to lose a child that you believed was being kept safe, creates a pain beyond measure and a deep searing anger," he said. He also called for the fine money to be used by the CQC to fund children’s mental health services, arguing that no financial penalty could ever "match the destruction that has been caused."
Chief nurse Dr. Maggie Davies, speaking on behalf of University Hospitals Sussex NHS Foundation Trust, expressed deep sorrow over Ellame’s death. "The loss of Ellame was a tragedy for her and for those who loved her. Colleagues involved in her care remain devastated by her death and the impact it continues to have on her family and friends," she said. Dr. Davies acknowledged the seriousness of what happened and the devastating impact on Ellame’s family and friends. "We had a responsibility to protect her while she was in our care, and we are sincerely sorry that we were not able to do that. Everyone accepts that people with acute mental illness should not be in general hospital wards or A&E departments, but that does not lessen our duty to keep patients safe whilst efforts are made to provide them with more appropriate care."
Since Ellame’s death, the trust has introduced significant improvements to its policies, training, and ward environments. Notably, a new missing persons policy now requires staff to take reasonable steps to prevent a patient from leaving a ward, to shout for help, alert security with an emergency bleep, follow the patient, and try to persuade them to return. If a patient leaves, staff must note the direction of travel and, in cases of immediate risk or where the patient is under section, notify the police immediately. These changes aim to prevent a repeat of the failures that led to Ellame’s death.
The inquest into Ellame’s death has been opened but remains adjourned, pending the outcome of the criminal case. When it resumes, it will examine not only the events of March 20 but also the period following her discharge from Chalkhill Hospital in January 2022, scrutinizing the adequacy of aftercare and the overall support provided to Ellame during her final weeks.
The case has reignited calls for urgent reform and investment in children’s mental health services. Experts and campaigners argue that the shortage of specialist beds, lack of safe environments, and unclear procedures continue to put vulnerable young people at risk. As Ellame’s story shows, the consequences of systemic failures can be devastating and far-reaching, leaving families with questions that no court ruling can ever truly answer.
While the trust’s apology and the court’s fine acknowledge responsibility, the loss of Ellame Ford-Dunn remains a stark reminder of the urgent need for safer, better-resourced care for the most vulnerable in society.
