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

9th March 2026

• 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 the partnerships and multidisciplinary working happening across the South East, which include:
• 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.