Ellame Ford-Dunn
3 Feb 2026 · Coroner Joanne Andrews · West Sussex, Brighton and Hove
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. insufficient Tier 4 Paediatric Mental Health beds
“I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission. I heard that the waiting time for a bed for those who are under the Kent and Sussex Child and Adolescent Mental Health Services (CAMHS) Inpatient Provider Collaborative is, on average, 8 days.”
2. use of acute paediatric wards for mental health patients without appropriate care
“I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to.”
3. inadequate locked facilities on acute paediatric ward
“I heard that at Worthing Hospital the Acute Paediatric Ward has been altered since [the deceased]'s death but due to fire regulations cannot be locked in the same way as a Tier 4 Paediatric Mental Health Unit would be and is not designed for the admission and treatment of children and young people with mental health concerns. I heard that the staff are not able to provide the mental health care that these patients are considered to require in their setting.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”
This report
“I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission.”
Closely relatedConfidence 0.90 · high
Earlier report
“Evidence given by the court appointed expert consultant psychiatrist was that Ms [name redacted] was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital.”
This report
“I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to.”