Ellame Ford-Dunn Prevention of future deaths report

Joanna Andrews 
HM Area Coroner for  
West Sussex, Brighton and Hove 
Record Office 
Orchard Street 
Chichester  
PO19 1DD 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

9th March 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ellame Ford-Dunn who 
died on 20th March 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  3rd 
February  2026  concerning  the  death  of  Ellame  Ford-Dunn  on  20th  March  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Ellame’s  family  and  loved  ones.  NHS  England  is 
keen to assure the family and yourself that the concerns raised about Ellame’s care 
have been listened to and reflected upon.   

Your Report raises concerns that there are insufficient numbers of Tier 4 paediatric 
mental health beds available for children and young people who have been assessed 
as  requiring  admission.  As  a  result,  University  Hospitals  Sussex  NHS  Foundation 
Trust  continues  to  have  a  number  of  children  and  young  people  on  their  acute 
paediatric wards with no physical health needs requiring treatment. Your Report also 
raises the concern that acute paediatric wards cannot be secured in the same way as 
a Tier 4 paediatric mental health unit would be and staff on these wards are unable to 
provide the required mental health care. 

Increasing  the  capacity  of  acute  paediatric  settings  to  support  children  and 
young people with a mental health need 

It  is  recognised  that  when  children  and  young  people  are  identified  as  requiring 
specialist children’s mental health care, a short admission to a paediatric ward may be 
appropriate  whilst  assessment  takes  place.  However,  due  to  complexities  and 
pressures  across  the  system,  increased  mental  health  needs,  or  a  breakdown  in  a 
social  care  placement,  some  children  and  young  people  may  remain  in  an  acute 
paediatric setting as a place of safety for longer periods than ideal.  

NHS England (NHSE) has been working to ensure that acute paediatric settings are 
able  to  provide  safe,  therapeutic  care  for  any  child  or  young  person  with  a  mental 
health need receiving treatment in them. In particular, since Ellame’s death:  

                                                                                                                       
 
 
 
                                                    
 
 
 
 
  
 
 
  
 • 

• 

In November 2022, NHSE published a framework for systems to support acute 
paediatric settings to provide holistic, appropriate care for children and young 
people  with  a  mental  health  need,  through  integrated  working  with  system 
partners (including community mental health, inpatient services and Voluntary, 
Community, and Social Enterprise organisations (VCSEs)) and the involvement 
of children, young people and their families. The framework also emphasises 
the  importance  of  education  and  training  for  the  paediatric  workforce  so  that 
they have the skills and confidence to support children and young people with 
a mental health need.  
In 2022, NHSE also launched a co-created single digital platform in partnership 
with Health Education England (HEE) and e-Learning for Health (eLfH) to host 
peer-reviewed  resources  and  training  modules  to  support  staff.  For  the  time 
period 15/10/2024 – 15/10/2025 there were over 192,000 active users of the 
platform, a 61% increase in the previous year.  

•  Funding for a Mental Health Champion across every provider was also made 
available  to  help  advocate  for  mental  health  and  support  parity  of  esteem  in 
paediatric  settings.  Individuals  in  these  roles  (and  others  with  an  interest  in 
increasing  awareness  and  understanding  of  mental  health  in  paediatric 
settings) are supported through a national Learning Collaborative.   

•  Led  by  clinical  advisors,  policy  teams  are  currently  working  with  NHSE’s 
Estates  team  to  produce  an  NHS  Estates  Technical  Bulletin  (NETB)  on  the 
design of the paediatric ward. This will incorporate recommendations from the 
Health Services Safety Investigations Body (HSSIB) and wider evidence on the 
importance of a therapeutic environment for children and young people with a 
mental health need.  

Our regional colleagues have advised that since Ellame’s death, specialised Eating 
Disorder & Psychiatric Intensive Care service capacity has expanded significantly in 
the  South  East  region,  to  include  specialised  alternatives  to  inpatient  admission 
(through NHS England capital & revenue medium-term funding schemes).  

Moreover,  waiting  times  for  inpatient  beds  have  now  reduced  significantly  since 
December 2023, with a sustained downward trend. Across financial years, the mean 
waiting time has fallen from 26.28 days in 2021/22 to less than 8 days in 2025/26. This 
figure varies case by case, but the overall reduction is substantial.  

In 2022, Sussex Integrated Care Board (ICB) alone had 17 young people waiting for 
specialised Child and Adolescent Mental Health Service (CAMHS) Tier 4 beds at one 
time,  with  over  70  waiting  across  the  region’s  critical  incident  operations.  In  March 
2022,  following  on  from  the  COVID-19  pandemic,  the  specialised  mental  health 
system  for  young  people  was  significantly  and  consistently  challenged  by  an 
exponential  increase  in  demand,  driven  by  an  emerging  need  for  specialist  mental 
health intervention and treatments (including nasogastric feeding). The compounding 
lack  of  nationwide  capacity,  ongoing  workforce  shortages,  and  emerging  clinical 
complexities also led to a decision to initiate a regional critical incident response, led 
by the Clinical Director for NHS England’s South East region. These challenges were 
compounded by novel service models that hadn't yet delivered sustainable solutions.  

As  of  January  2026,  the  average  number  of  Sussex  young  people  waiting  for  a 
specialised inpatient bed was 2.3, and these individuals had admission plans in place 

 or were in the process of being assessed for admission to an inpatient bed that had 
already been identified. A recent NHS England regional situation report from January 
2026 showed six young people waiting for new admissions regionally. 

Providing more intensive support at home and in the community, and avoiding 
inappropriate admissions 

In  2024,  NHS  England  published  updated  implementation  guidance  on  urgent  and 
emergency  mental  health  care  for  children  and  young  people,  which  set  out  the 
components of a comprehensive 24/7 offer that must be available to all children and 
young people experiencing mental health crisis. As well as a single point of access 
through NHS 111, the offer should include brief interventions in the community and 
intensive  home  treatment,  avoiding  admissions  to  hospital  where  these  are  not 
necessary and helping to ensure that beds are available for those who do need them.   

The guidance illustrates the core capabilities and skills that are required across the 
children  and  young  people’s  urgent  and  emergency  and  crisis  pathways,  to  assist 
colleagues in effectively fulfilling their roles. Underpinning the attributes, capabilities 
and skills are the core principles of staff adopting a compassionate, trauma-informed 
and empathetic approach. This includes actively listening and giving the child, young 
person, family and carers the opportunity to be heard. 

From a regional perspective, there has been substantial investment in Intensive Home 
Treatment  Services  (COAST)  in  Sussex,  either  directly  via  NHS  England  funded 
schemes  or  directly  via  the  Lead  Provider  Trust  and/or  Sussex  ICB  and  Sussex 
Partnership  NHS  Foundation  Trust.  These  services  have  been  co-produced  with 
young  people  with  lived  experience  and  their  parents,  families  and  carers.  These 
services, now established across all counties in the Sussex Integrated Care System 
(ICS) geography, currently provide: 

• 

Intensive  home  treatment,  as  an  effective  alternative  to  admission,  allowing 
young people to remain in their home or usual place of residence, where it is 
safe  to  do  so,  with  continued  access  to  their  family  and  friendship  support 
networks. 

•  Early and effective discharge planning and reducing prolonged lengths of stay 
in hospital settings. This, in turn, prevents the potential dependency on inpatient 
admissions. 

•  Access  to advice,  guidance and  support to  acute paediatric clinical teams  to 
safely manage young  people admitted to  paediatric wards.  This  includes  the 
funding and establishment of ‘Mental Health Champions’ – clinical leads with a 
specialist  interest  and  training  in  mental  health  needs  of  children  &  young 
people.  

•  During  the  surge  in  referrals  in  2021/22  and  the  post-COVID  increase  in 
demand, NHS England and the Provider Collaboratives also funded additional 
support  workers  and  nurses  in  paediatric  wards,  along  with  regional  mental 
health training, such as the Oliver McGowan training in the recognition of the 
needs of young people with Autism and/or ADHD in healthcare settings. 

Regional  NHS  England  colleagues  have  highlighted  the  alternatives  to  inpatient 
admission that are available in the area. These are: 

 •  The Springtide Eating Disorder Day Service in Hove, West Sussex which offers 
10 day spaces, providing an alternative to inpatient admission with family-based 
therapy and interventions that support step-down and transition from a hospital 
admission, enabling timely discharge from inpatient settings. 

•  A  new  Transition  Service  (from  2026),  which  has  a  role  in  supporting  young 
people as they are discharged from hospital. This builds on a successful model 
already established in both Dorset and Hampshire. The team begins working 
with  young  people while they  are  still  in  hospital and  continues support  after 
discharge and incorporates a specialist, multidisciplinary service model.  

Ensuring a joined-up pathway 

Whilst continuing to share the above publications and initiatives, NHSE supports the 
joining up of services and stakeholders across the crisis and acute pathway to support 
services to work together to meet the needs of every child. We have recently convened 
a national Crisis and Acute Stakeholder Forum to bring together NHS organisations, 
regulatory and professional bodies, VCSEs and people with lived experience to ensure 
that we are working collectively and identifying priorities for further improvement. 

Regional  NHS  England  colleagues  have  highlighted 
multidisciplinary working happening across the South East, which include: 

the  partnerships  and 

•  The Southern Counties Provider Collaborative’s Urgent and Emergency care 
pathway group, which includes the Integrated Care System, Local Authority and 
NHS Acute Trusts across Sussex. 

•  A  new  tri-funded  short-term  residential  alternative  to  hospital  admission  is 
expected to open in 2026. This provides a setting (outside of hospital) to meet 
the needs of young people in crisis, especially those with Learning Disabilities 
and / or Autism where there is no co-occurring mental health diagnosis. 

•  The  Provider  Collaborative  also  provided  £180,000  to  University  Hospitals 
Sussex NHS Foundation Trust to support the recruitment of additional mental 
health nurses to support young people admitted to paediatric wards or attending 
Emergency departments with mental health needs. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Ellame, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
  
 
 National Medical Director  
NHS England