Raihana Oluwadamilola Awolaja
PFD Report
All Responded
Ref: 2025-0212
All 1 response received
· Deadline: 14 Jul 2025
Sent To
Response Status
Responses
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56-Day Deadline
14 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.
Responses
The Children's Trust has implemented mandatory training on monitoring and observation, introduced a floating staff role, and allocated dedicated administrative support. They also thoroughly reviewed incident reporting, integrated PSIRF, embedded restorative practice, and subject significant safeguarding incidents to independent review.
AI summary
View full response
The Children’s Trust Response to Regulation 28 Report Issued by HM Senior Coroner, Professor Fiona J Wilcox Following the Death of Raihana Oluwadamilola Awolaja
Acknowledgement of Loss and Coroner’s Findings We would like to express our deepest sympathy to the family and loved ones of Raihana Oluwadamilola Awolaja. Raihana was a much-loved young person whose tragic death has had a profound impact on our team and the way we care for, support, and involve the children and families we work with today at The Children’s Trust. We recognise the serious concerns raised by the coroner and are committed to addressing each of them fully. Raihana’s death has prompted significant reflection, change, and action across our organisation.
1. Safe Staffing and One-to-One Care Coroner’s Concerns:
• Children like Raihana are not always receiving the level of one-to-one care and supervision they require.
• Staff may lack clarity or training in what one-to-one care looks like in practice.
• Administrative duties may be prioritised over care. Actions Taken:
• Mandatory Training: All care giving staff now receive mandatory, specific training on our monitoring and observation policy, including clear guidance on what one-to-one care entails at The Children’s Trust. This training covers essential aspects such as proximity, engagement, and supervision.
• Floating Staff Role Introduced: We have introduced a flexible “floating” staff role available 24 hours a day. This role ensures that additional support can be provided promptly whenever needed, guaranteeing that children and young people consistently receive the appropriate level of care and supervision without interruption.
• Dedicated Administrative Support: Each house has been allocated a dedicated administrator, allowing care staff to focus on their primary caregiving responsibilities without being unduly distracted by administrative tasks.
• Role Clarity: We have clarified staff roles to ensure that direct care is prioritised over administrative duties. Staff have been formally instructed on this expectation.
• Improved Handover Protocols: Shift handovers now follow a standardised, structured protocol supported by clear tools to ensure comprehensive transfer of information between teams, reducing the risk of important details being missed.
• Clinical Site Management: A Clinical Site Manager, a senior nurse, is now present on site 24 hours a day. This role allows immediate response to any clinical issues or escalations, enhancing clinical oversight and quality of care.
• Routine Audits: In addition to regular monitoring and observation audits, Clinical Site Managers conduct routine overnight audits. These are systematically reviewed to maintain high standards of care.
• Delegation Policy: As part of our revised Delegation Policy, The Children’s Trust now requires that every staff member allocated to provide one-to-one care for a child or young person, formally sign at the start of each shift to confirm their understanding of that individual’s care, monitoring, and observation needs; furthermore, they must seek approval from the shift leader before stepping away at any time during the shift, including for breaks, and must obtain permission to leave at the end of their shift to ensure safe and continuous care with no gaps during handovers. In Progress:
• We are in the process of embedding a revised evidence-based staffing model aligned with national standards. This model aims to continue to ensure the appropriate number and mix of staff are available according to the individual needs of each child.
2. Incident Investigation and Accountability Coroner’s Concerns:
• A flawed investigation shifted blame onto an individual, failing to address broader systemic issues.
• A flawed investigation risks missing key lessons that could prevent future harm. Response:
• We accept that the initial external investigation was inadequate and did not sufficiently explore systemic factors. We later identified and reported these issues in our Serious Incident Report and undertook further work.
• A revised internal investigation led by our Risk and Legal team provided a more comprehensive understanding and drove meaningful changes. Actions Taken:
• Incident Management Policies and Processes: We have developed and implemented a revised incident management policy and process that incorporates national best practice standards to ensure robust and consistent handling of all incidents
• Clinical Governance Framework: Significant investment has been made in strengthening our clinical governance framework. This enhancement enables us to better identify and respond to recurring themes and trends, promoting continuous organisational learning and improvement.
• PSIRF Implementation: We have fully implemented the national Patient Safety Incident Response Framework (PSIRF) to guide all incident investigations, ensuring a consistent, transparent, and learning-focused approach.
• Multidisciplinary Panels: All incidents are now reviewed by multidisciplinary panels comprising of representatives from across the organisation, facilitating a comprehensive and collaborative review process.
• Internal Oversight of External Reviews: Investigations commissioned externally are now subject to additional internal oversight through our governance procedures. This internal review ensures that external findings are scrutinised rigorously and challenged appropriately to maintain high standards of accountability.
Additional Review:
• An independent review is currently underway to examine how we managed the investigation and disciplinary process related to this case. This review, due for completion by 30 June 2025, will also evaluate governance arrangements, equality considerations, and the potential influence that the PSIRF framework might have had at the time.
3. Communication with Families and Local Authorities Coroner’s Concerns:
• Raihana’s mother and the local authority were not informed about key developments, such as disciplinary proceedings.
• This lack of communication increases risks to vulnerable children. Actions Taken:
• New Communication Protocols: We have implemented new communication protocols to ensure that all serious care or safeguarding concerns are promptly and transparently shared with the child’s family and the relevant local authority. This is done in accordance with the Patient Safety Incident Response Framework (PSIRF) and our updated incident management policy and procedures.
• Governance Oversight: To ensure accountability and transparency, all such communications are systematically recorded and reviewed by our governance teams. These processes have also been independently reviewed by external regulators, confirming their effectiveness. System-Level Improvements:
• Risk Summit: In November 2024, we convened a Risk Summit involving NHS England, regulatory bodies, health and social care partners, and commissioners. This summit
focused on improving access to specialist NHS services and reviewing our monitoring and observation policies to enhance the safety and quality of care provided.
4. Listening to Families and Handling Complaints Coroner’s Concerns:
• Families were not always listened to or taken seriously.
• Complaints may have been dismissed without thorough investigation. Actions Taken:
• Family Satisfaction Surveys: We have introduced quarterly Family Satisfaction Surveys, which families can complete anonymously if they wish. Feedback from these surveys is carefully reviewed and acted upon. Outcomes are escalated through our governance structure to ensure they directly influence service improvements and decision-making.
• Monthly Family Forum: A Monthly Family Forum has been established, attended by senior leaders including the Head Teacher and Chief Executive Officer. This forum provides a protected and supportive environment where parents, families, and carers can provide feedback, ask questions, and raise concerns. Discussions and themes from these meetings are formally documented, with agreed actions monitored and followed up at subsequent forums.
• Increased Resource: To strengthen the organisation’s responsiveness, we have created a dedicated Clinical Governance Department. This department includes a senior role (Band 8a) specifically responsible for championing the experiences and perspectives of children, young people, and their families. This role ensures that their voices are embedded at every level of the organisation, with concerns and feedback escalated consistently and with appropriate oversight. In Progress:
• Revised Complaints Policy: We are currently revising our Complaints Policy and process. This work involves a thorough review across the organisation to identify and address any gaps, ensuring the process is robust and aligned with national best practice standards.
• Modified Martha’s Rule: We are introducing a modified escalation procedure, often referred to as “Martha’s Rule,” which will provide families with a clear and accessible route to request a second opinion or further review when they have concerns about the care provided.
5. Internal Communication and Planning Coroner’s Concerns:
• Information shared in planning or safeguarding meetings wasn’t always passed on to the frontline staff delivering care. Actions Taken:
• Standardised Handover Protocols: We have introduced standardised handover protocols to ensure that all shift handovers consistently include relevant updates from planning and safeguarding meetings. These handovers follow a structured format that is regularly audited to maintain compliance and effectiveness.
• Electronic Patient Records: All care decisions and updates are now recorded within a comprehensive electronic patient records system. This system ensures that care staff have real-time access to accurate and up-to-date information, supporting continuity and quality of care across the organisation.
6. Organisational Culture and Staff Confidence Coroner’s Concerns:
• Concerns were raised that staff might feel unable to speak up or challenge poor practice. Actions Taken:
• Nursing and Care / Clinical Governance Restructure: We have undertaken a significant restructure within our largest directorate, Nursing and Care. This restructure strengthens clinical governance, risk management, clinical education, and operational leadership across the site to ensure improved oversight and quality of care.
• Freedom to Speak Up: In February 2025, we adopted the NHS-aligned Freedom to Speak Up framework and appointed an independent Guardian to support staff in raising concerns safely and confidentially. This represents a major commitment for our organisation, which is a smaller, non-NHS provider, but we believe it is essential to provide a safe, independent route for staff to raise concerns and ensure they are addressed with full organisational accountability.
• Psychological Safety: To promote psychological safety, we hold regular reflective safeguarding sessions and learning forums. These initiatives foster a culture of openness, transparency, and continuous improvement among staff. In addition, we are currently training 30 of our most senior staff and 53 first line managers in relation to psychological safety as part of a wider leadership development programme launched in 2025.
• Thematic Reviews: We conduct thematic reviews of all serious incidents to identify recurring issues. The findings from these reviews directly inform staff training and ongoing service improvements.
• Culture and Values: Our culture and values underpin everything we do and our organisational ‘promises’ – to put children first, to care deeply, to aim high, to be open, and to own it – developed in collaboration with our staff, volunteers, partners and children, young people and families, always guide us in the way we work and the decisions we make everyday.
Ongoing Commitment We remain committed to embedding these improvements in a sustainable way, ensuring they are not one-off responses but part of a systemic shift in how we deliver care, learn from harm, and work with families and professionals. We are confident that our current systems, informed by the national Patient Safety Incident Response Framework, are significantly more robust and responsive than at the time of Raihana’s death. However, we also remain humble in our approach and open to continued challenge and oversight. We also acknowledge that the issues raised in Raihana’s case do not exist in isolation. The safety and wellbeing of children with complex needs requires a coordinated and transparent approach across the wider health and social care system. As such, we continue to work closely with our NHS and local authority partners to ensure risks are shared, escalated, and addressed collaboratively. Our continued progress is subject to internal audit, external regulatory inspection from both OFSTED Care and the Care Quality Commission, and multi-agency oversight. In October 2024, we were rated as ‘Good’ by OFSTED Care who also inspected in January 2025 with no change to our rating. Both the Care Quality Commission and OFSTED Care have conducted targeted inspections over the last 12 months covering the areas detailed within this response providing us with significant assurance that this improvement work is embedded within practice.
Conclusion Raihana’s death has been a catalyst for fundamental change across The Children’s Trust. We recognise that serious and avoidable failures occurred, and we are resolute in our commitment to improvement. We take the coroner’s concerns extremely seriously and have acted swiftly and extensively. We are confident that the measures we have already introduced will strengthen safety, communication, and trust across our services, and we know there is still more to do. We remain focused on our duty to every child in our care, and on ensuring that Raihana’s legacy is one of learning, accountability, and lasting change.
Acknowledgement of Loss and Coroner’s Findings We would like to express our deepest sympathy to the family and loved ones of Raihana Oluwadamilola Awolaja. Raihana was a much-loved young person whose tragic death has had a profound impact on our team and the way we care for, support, and involve the children and families we work with today at The Children’s Trust. We recognise the serious concerns raised by the coroner and are committed to addressing each of them fully. Raihana’s death has prompted significant reflection, change, and action across our organisation.
1. Safe Staffing and One-to-One Care Coroner’s Concerns:
• Children like Raihana are not always receiving the level of one-to-one care and supervision they require.
• Staff may lack clarity or training in what one-to-one care looks like in practice.
• Administrative duties may be prioritised over care. Actions Taken:
• Mandatory Training: All care giving staff now receive mandatory, specific training on our monitoring and observation policy, including clear guidance on what one-to-one care entails at The Children’s Trust. This training covers essential aspects such as proximity, engagement, and supervision.
• Floating Staff Role Introduced: We have introduced a flexible “floating” staff role available 24 hours a day. This role ensures that additional support can be provided promptly whenever needed, guaranteeing that children and young people consistently receive the appropriate level of care and supervision without interruption.
• Dedicated Administrative Support: Each house has been allocated a dedicated administrator, allowing care staff to focus on their primary caregiving responsibilities without being unduly distracted by administrative tasks.
• Role Clarity: We have clarified staff roles to ensure that direct care is prioritised over administrative duties. Staff have been formally instructed on this expectation.
• Improved Handover Protocols: Shift handovers now follow a standardised, structured protocol supported by clear tools to ensure comprehensive transfer of information between teams, reducing the risk of important details being missed.
• Clinical Site Management: A Clinical Site Manager, a senior nurse, is now present on site 24 hours a day. This role allows immediate response to any clinical issues or escalations, enhancing clinical oversight and quality of care.
• Routine Audits: In addition to regular monitoring and observation audits, Clinical Site Managers conduct routine overnight audits. These are systematically reviewed to maintain high standards of care.
• Delegation Policy: As part of our revised Delegation Policy, The Children’s Trust now requires that every staff member allocated to provide one-to-one care for a child or young person, formally sign at the start of each shift to confirm their understanding of that individual’s care, monitoring, and observation needs; furthermore, they must seek approval from the shift leader before stepping away at any time during the shift, including for breaks, and must obtain permission to leave at the end of their shift to ensure safe and continuous care with no gaps during handovers. In Progress:
• We are in the process of embedding a revised evidence-based staffing model aligned with national standards. This model aims to continue to ensure the appropriate number and mix of staff are available according to the individual needs of each child.
2. Incident Investigation and Accountability Coroner’s Concerns:
• A flawed investigation shifted blame onto an individual, failing to address broader systemic issues.
• A flawed investigation risks missing key lessons that could prevent future harm. Response:
• We accept that the initial external investigation was inadequate and did not sufficiently explore systemic factors. We later identified and reported these issues in our Serious Incident Report and undertook further work.
• A revised internal investigation led by our Risk and Legal team provided a more comprehensive understanding and drove meaningful changes. Actions Taken:
• Incident Management Policies and Processes: We have developed and implemented a revised incident management policy and process that incorporates national best practice standards to ensure robust and consistent handling of all incidents
• Clinical Governance Framework: Significant investment has been made in strengthening our clinical governance framework. This enhancement enables us to better identify and respond to recurring themes and trends, promoting continuous organisational learning and improvement.
• PSIRF Implementation: We have fully implemented the national Patient Safety Incident Response Framework (PSIRF) to guide all incident investigations, ensuring a consistent, transparent, and learning-focused approach.
• Multidisciplinary Panels: All incidents are now reviewed by multidisciplinary panels comprising of representatives from across the organisation, facilitating a comprehensive and collaborative review process.
• Internal Oversight of External Reviews: Investigations commissioned externally are now subject to additional internal oversight through our governance procedures. This internal review ensures that external findings are scrutinised rigorously and challenged appropriately to maintain high standards of accountability.
Additional Review:
• An independent review is currently underway to examine how we managed the investigation and disciplinary process related to this case. This review, due for completion by 30 June 2025, will also evaluate governance arrangements, equality considerations, and the potential influence that the PSIRF framework might have had at the time.
3. Communication with Families and Local Authorities Coroner’s Concerns:
• Raihana’s mother and the local authority were not informed about key developments, such as disciplinary proceedings.
• This lack of communication increases risks to vulnerable children. Actions Taken:
• New Communication Protocols: We have implemented new communication protocols to ensure that all serious care or safeguarding concerns are promptly and transparently shared with the child’s family and the relevant local authority. This is done in accordance with the Patient Safety Incident Response Framework (PSIRF) and our updated incident management policy and procedures.
• Governance Oversight: To ensure accountability and transparency, all such communications are systematically recorded and reviewed by our governance teams. These processes have also been independently reviewed by external regulators, confirming their effectiveness. System-Level Improvements:
• Risk Summit: In November 2024, we convened a Risk Summit involving NHS England, regulatory bodies, health and social care partners, and commissioners. This summit
focused on improving access to specialist NHS services and reviewing our monitoring and observation policies to enhance the safety and quality of care provided.
4. Listening to Families and Handling Complaints Coroner’s Concerns:
• Families were not always listened to or taken seriously.
• Complaints may have been dismissed without thorough investigation. Actions Taken:
• Family Satisfaction Surveys: We have introduced quarterly Family Satisfaction Surveys, which families can complete anonymously if they wish. Feedback from these surveys is carefully reviewed and acted upon. Outcomes are escalated through our governance structure to ensure they directly influence service improvements and decision-making.
• Monthly Family Forum: A Monthly Family Forum has been established, attended by senior leaders including the Head Teacher and Chief Executive Officer. This forum provides a protected and supportive environment where parents, families, and carers can provide feedback, ask questions, and raise concerns. Discussions and themes from these meetings are formally documented, with agreed actions monitored and followed up at subsequent forums.
• Increased Resource: To strengthen the organisation’s responsiveness, we have created a dedicated Clinical Governance Department. This department includes a senior role (Band 8a) specifically responsible for championing the experiences and perspectives of children, young people, and their families. This role ensures that their voices are embedded at every level of the organisation, with concerns and feedback escalated consistently and with appropriate oversight. In Progress:
• Revised Complaints Policy: We are currently revising our Complaints Policy and process. This work involves a thorough review across the organisation to identify and address any gaps, ensuring the process is robust and aligned with national best practice standards.
• Modified Martha’s Rule: We are introducing a modified escalation procedure, often referred to as “Martha’s Rule,” which will provide families with a clear and accessible route to request a second opinion or further review when they have concerns about the care provided.
5. Internal Communication and Planning Coroner’s Concerns:
• Information shared in planning or safeguarding meetings wasn’t always passed on to the frontline staff delivering care. Actions Taken:
• Standardised Handover Protocols: We have introduced standardised handover protocols to ensure that all shift handovers consistently include relevant updates from planning and safeguarding meetings. These handovers follow a structured format that is regularly audited to maintain compliance and effectiveness.
• Electronic Patient Records: All care decisions and updates are now recorded within a comprehensive electronic patient records system. This system ensures that care staff have real-time access to accurate and up-to-date information, supporting continuity and quality of care across the organisation.
6. Organisational Culture and Staff Confidence Coroner’s Concerns:
• Concerns were raised that staff might feel unable to speak up or challenge poor practice. Actions Taken:
• Nursing and Care / Clinical Governance Restructure: We have undertaken a significant restructure within our largest directorate, Nursing and Care. This restructure strengthens clinical governance, risk management, clinical education, and operational leadership across the site to ensure improved oversight and quality of care.
• Freedom to Speak Up: In February 2025, we adopted the NHS-aligned Freedom to Speak Up framework and appointed an independent Guardian to support staff in raising concerns safely and confidentially. This represents a major commitment for our organisation, which is a smaller, non-NHS provider, but we believe it is essential to provide a safe, independent route for staff to raise concerns and ensure they are addressed with full organisational accountability.
• Psychological Safety: To promote psychological safety, we hold regular reflective safeguarding sessions and learning forums. These initiatives foster a culture of openness, transparency, and continuous improvement among staff. In addition, we are currently training 30 of our most senior staff and 53 first line managers in relation to psychological safety as part of a wider leadership development programme launched in 2025.
• Thematic Reviews: We conduct thematic reviews of all serious incidents to identify recurring issues. The findings from these reviews directly inform staff training and ongoing service improvements.
• Culture and Values: Our culture and values underpin everything we do and our organisational ‘promises’ – to put children first, to care deeply, to aim high, to be open, and to own it – developed in collaboration with our staff, volunteers, partners and children, young people and families, always guide us in the way we work and the decisions we make everyday.
Ongoing Commitment We remain committed to embedding these improvements in a sustainable way, ensuring they are not one-off responses but part of a systemic shift in how we deliver care, learn from harm, and work with families and professionals. We are confident that our current systems, informed by the national Patient Safety Incident Response Framework, are significantly more robust and responsive than at the time of Raihana’s death. However, we also remain humble in our approach and open to continued challenge and oversight. We also acknowledge that the issues raised in Raihana’s case do not exist in isolation. The safety and wellbeing of children with complex needs requires a coordinated and transparent approach across the wider health and social care system. As such, we continue to work closely with our NHS and local authority partners to ensure risks are shared, escalated, and addressed collaboratively. Our continued progress is subject to internal audit, external regulatory inspection from both OFSTED Care and the Care Quality Commission, and multi-agency oversight. In October 2024, we were rated as ‘Good’ by OFSTED Care who also inspected in January 2025 with no change to our rating. Both the Care Quality Commission and OFSTED Care have conducted targeted inspections over the last 12 months covering the areas detailed within this response providing us with significant assurance that this improvement work is embedded within practice.
Conclusion Raihana’s death has been a catalyst for fundamental change across The Children’s Trust. We recognise that serious and avoidable failures occurred, and we are resolute in our commitment to improvement. We take the coroner’s concerns extremely seriously and have acted swiftly and extensively. We are confident that the measures we have already introduced will strengthen safety, communication, and trust across our services, and we know there is still more to do. We remain focused on our duty to every child in our care, and on ensuring that Raihana’s legacy is one of learning, accountability, and lasting change.
Action Should Be Taken
It is for each addressee to respond to matters relevant to them.
Report Sections
Investigation and Inquest
From 7th April to 9th April 2025 evidence was heard touching the death of Raihana Oluwadamilola Awolaja. She had died on the 1st June 2023 aged 12 years at St George’s Hospital, Blackshaw Road, Tooting, London. She had died after she had been left unsupervised in her residential care home, The Children’s Trust, Tadworth Court, for approximately fifteen minutes, despite being on one-to-one care for tracheostomy care and other medical conditions and disabilities. Her tracheostomy tube was blocked by secretions and as no carer was present to clear it, she suffered respiratory compromise and arrested. She was resuscitated at the scene but later died of hypoxic brain injury. Medical Cause of Death 1 a. Hypoxic ischaemic brain injury 1b Cardiac arrest 1c Post viral respiratory secretions II Pneumonia How, when, where and in what circumstances the deceased came by her death: Raihana had been born prematurely at only 27 weeks gestation and as such suffered with significant medical illnesses and disabilities. She was tracheostomy dependent for breathing. She was resident at the Children’s Trust (TCT) where she should have received one to one nursing care to safeguard her tracheostomy.
She had recently suffered viral pneumonia requiring ventilation on PICU and was discharged back to TCT on 23rd May 2023. She was recovering from the pneumonia but still had some increased respiratory secretions requiring an increase in nebulisation therapy and increasing her respiratory vulnerability. On 29/5/2023 her allocated carer left the unit to undertake an administrative task at 19:25-19:30, handing over her nursing care to a nurse due to go off shift. At approximately 19:35, this nurse in turn handed over to another nurse (nurse two) as her shift had ended. Nurse two did not supervise Raihana, instead was caring for another child. At approximately 19:50 Raihana’s allocated nurse returned to find that Raihanna had arrested. The alarm was raised, CPR started, and an ambulance called. A return of circulation was achieved at 20:26 and Raihana was transferred to St George’s Hospital. Sadly, she died of hypoxic ischaemic brain injury at 19:34 hours on 01/06/2023. Her arrest had been caused by secretions partially blocking her tracheostomy tube. If she had been appropriately observed between 19:35 and 19:50 this would have been recognised and resolved and on the balance of probabilities she would not have died at this time. This failure to adequately observe her was a gross failure in care by the nursing staff. This was compounded by the lack of sufficient staff on the unit where Raihana lived to provide proper 1:1 care. Final Conclusion: Natural Causes Contributed to by neglect. Evidence relevant to the matters of concern. Extensive evidence was taken and exhibited and some potential regulation 28 matters explored. Of relevance to this report:
1. Raihana’s mother raised on a number of occasions that her daughter, contrary to the agreed level of around the clock one to one care, with two to one for personal care, she had observed her daughter to be left with no supervising carer. This was discussed at meetings at the TCT but continued to happen. In particular a written complaint made by Raihana’s mother raised this matter and gave a detailed example. This was responded to by TCT by a generic response that Raihana did receive appropriate care without any evidence that the specific example raised was investigated or acted upon.
2. Subsequent to this complaint a member of TCT staff was disciplined in relation to a further occasion when Raihana was left alone, but neither Raihana’s named social worker from the London Borough of Croydon, nor Raihana’s mother were informed.
3. There were multiple meetings between Raihana’s mother, the named social worker and managers at TCT at which various matters of concern were raised. There was no evidence that these matters nor actions to address them were sufficiently communicated to those caring for Raihana on a day-to-day basis.
4. The carer allocated to look after Raihana at the material time left the unit and went to another unit to fetch a laminator. It was while she was absent that Raihana arrested.
5. Following Raihana’s death, TCT undertook an investigation which failed to uncover what had happened or to understand the cause of her death. This meant that a nurse, to whom Raihana’s care had been handed to by the allocated carer was blamed by the TCT and was referred to the NMC erroneously. Evidence taken at the inquiry found issues with the credibility of another nurse (nurse two) who should have been caring for Raihana, this responsibility having been handed over to her by the first nurse leaving as her shift was over. This was supported by evidential inconsistencies between witnesses, timing matters and evidence given contemporaneously that should have been evident when TCT investigated.
6. Evidence was taken as to what one to one meant in practice that highlighted for hours every day Raihana would have been on one to two care, once meetings, breaks, handovers, requirement for two to one to be given to other residents, and medication administration etc. was factored in. There were simply insufficient staff to provide constant one to one care, as understood it should have been provided and commissioned by the LA. There was confusion as to what one to one meant at the time of the Raihana’s death and how it is practiced now by carers and nurses who gave evidence. There will still be occasions when vulnerable residents such as Raihana will be left one to two, with eyes on only observation, despite an apparent increase in numbers of staff on duty at any one time, albeit it should happen less often. Matters of Concern
1. That children such as Raihana requiring one to one care are still at times receiving less intensive care and supervision than they require.
2. That there may be culture of cover up at the TCT, in that they carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths.
3. That TCT do not sufficiently communicate with the commissioning LA nor next of kin in relation to issues with care and supervision, for example not informing the named social worker nor the mother of the disciplinary proceedings against a staff member who left Raihana alone. This in turn leaves vulnerable residents at risk, as the named social workers and possibly the commissioning authority nor the next of kin will be aware of potential increased risks to the vulnerable child. This matter also goes to matter 2 above.
4. That there may be staff training issues in relation to what one to one care means in practice.
5. That there may be training issues in relation to the prioritisation of administrative tasks above care.
6. That next of kin are not sufficiently listened to when they raise concerns, and their complaints are dismissed without sufficient investigation.
7. That the systems of communication between those attending planning and review meetings and those providing care to the residents are inadequate, such that matters raised at these meetings and any actions agreed to address them are insufficiently communicated to those providing care to the residents.
She had recently suffered viral pneumonia requiring ventilation on PICU and was discharged back to TCT on 23rd May 2023. She was recovering from the pneumonia but still had some increased respiratory secretions requiring an increase in nebulisation therapy and increasing her respiratory vulnerability. On 29/5/2023 her allocated carer left the unit to undertake an administrative task at 19:25-19:30, handing over her nursing care to a nurse due to go off shift. At approximately 19:35, this nurse in turn handed over to another nurse (nurse two) as her shift had ended. Nurse two did not supervise Raihana, instead was caring for another child. At approximately 19:50 Raihana’s allocated nurse returned to find that Raihanna had arrested. The alarm was raised, CPR started, and an ambulance called. A return of circulation was achieved at 20:26 and Raihana was transferred to St George’s Hospital. Sadly, she died of hypoxic ischaemic brain injury at 19:34 hours on 01/06/2023. Her arrest had been caused by secretions partially blocking her tracheostomy tube. If she had been appropriately observed between 19:35 and 19:50 this would have been recognised and resolved and on the balance of probabilities she would not have died at this time. This failure to adequately observe her was a gross failure in care by the nursing staff. This was compounded by the lack of sufficient staff on the unit where Raihana lived to provide proper 1:1 care. Final Conclusion: Natural Causes Contributed to by neglect. Evidence relevant to the matters of concern. Extensive evidence was taken and exhibited and some potential regulation 28 matters explored. Of relevance to this report:
1. Raihana’s mother raised on a number of occasions that her daughter, contrary to the agreed level of around the clock one to one care, with two to one for personal care, she had observed her daughter to be left with no supervising carer. This was discussed at meetings at the TCT but continued to happen. In particular a written complaint made by Raihana’s mother raised this matter and gave a detailed example. This was responded to by TCT by a generic response that Raihana did receive appropriate care without any evidence that the specific example raised was investigated or acted upon.
2. Subsequent to this complaint a member of TCT staff was disciplined in relation to a further occasion when Raihana was left alone, but neither Raihana’s named social worker from the London Borough of Croydon, nor Raihana’s mother were informed.
3. There were multiple meetings between Raihana’s mother, the named social worker and managers at TCT at which various matters of concern were raised. There was no evidence that these matters nor actions to address them were sufficiently communicated to those caring for Raihana on a day-to-day basis.
4. The carer allocated to look after Raihana at the material time left the unit and went to another unit to fetch a laminator. It was while she was absent that Raihana arrested.
5. Following Raihana’s death, TCT undertook an investigation which failed to uncover what had happened or to understand the cause of her death. This meant that a nurse, to whom Raihana’s care had been handed to by the allocated carer was blamed by the TCT and was referred to the NMC erroneously. Evidence taken at the inquiry found issues with the credibility of another nurse (nurse two) who should have been caring for Raihana, this responsibility having been handed over to her by the first nurse leaving as her shift was over. This was supported by evidential inconsistencies between witnesses, timing matters and evidence given contemporaneously that should have been evident when TCT investigated.
6. Evidence was taken as to what one to one meant in practice that highlighted for hours every day Raihana would have been on one to two care, once meetings, breaks, handovers, requirement for two to one to be given to other residents, and medication administration etc. was factored in. There were simply insufficient staff to provide constant one to one care, as understood it should have been provided and commissioned by the LA. There was confusion as to what one to one meant at the time of the Raihana’s death and how it is practiced now by carers and nurses who gave evidence. There will still be occasions when vulnerable residents such as Raihana will be left one to two, with eyes on only observation, despite an apparent increase in numbers of staff on duty at any one time, albeit it should happen less often. Matters of Concern
1. That children such as Raihana requiring one to one care are still at times receiving less intensive care and supervision than they require.
2. That there may be culture of cover up at the TCT, in that they carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths.
3. That TCT do not sufficiently communicate with the commissioning LA nor next of kin in relation to issues with care and supervision, for example not informing the named social worker nor the mother of the disciplinary proceedings against a staff member who left Raihana alone. This in turn leaves vulnerable residents at risk, as the named social workers and possibly the commissioning authority nor the next of kin will be aware of potential increased risks to the vulnerable child. This matter also goes to matter 2 above.
4. That there may be staff training issues in relation to what one to one care means in practice.
5. That there may be training issues in relation to the prioritisation of administrative tasks above care.
6. That next of kin are not sufficiently listened to when they raise concerns, and their complaints are dismissed without sufficient investigation.
7. That the systems of communication between those attending planning and review meetings and those providing care to the residents are inadequate, such that matters raised at these meetings and any actions agreed to address them are insufficiently communicated to those providing care to the residents.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.