Concerns raised 7 Flawed investigations failing to identify systemic failures and learning View source Insufficient staff training on what one-to-one care means in practice View source Failure to listen to and sufficiently investigate concerns and complaints raised by next of kin View source Insufficient communication with commissioning authorities and next of kin about care and supervision risks View source Inadequate communication of planning and review meeting matters and actions to care providers View source Failure to provide children requiring one-to-one care with sufficiently intensive care and supervision View source Insufficient staff training on prioritising care over administrative tasks View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Flawed investigations failing to identify systemic failures and learning
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training on what one-to-one care means in practice
Wider context from the report “4. That there may be staff training issues in relation to what one to one care means in practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to listen to and sufficiently investigate concerns and complaints raised by next of kin
Wider context from the report “6. That next of kin are not sufficiently listened to when they raise concerns , and their complaints are dismissed without sufficient investigation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication with commissioning authorities and next of kin about care and supervision risks
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of planning and review meeting matters and actions to care providers
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide children requiring one-to-one care with sufficiently intensive care and supervision
Wider context from the report “1. That children such as Raihana requiring one to one care are still at times receiving less intensive care and supervision than they require .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training on prioritising care over administrative tasks
Wider context from the report “5. That there may be training issues in relation to the prioritisation of administrative tasks above care .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national Patient Safety Incident Response Framework for incident investigations.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify staff roles and formally prioritise direct care over administrative duties.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen the clinical governance framework to identify recurring themes and trends and support organisational learning.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Clinical Governance Department and a senior role championing children’s and families’ experiences.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the complaints policy and process to address gaps and align with national best practice.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly anonymous Family Satisfaction Surveys and use their findings in governance-led service improvements.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct thematic reviews of serious incidents and use findings to inform staff training and service improvements.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all incidents through multidisciplinary panels representing the organisation.
Verbatim wording from the response “• Multidisciplinary Panels: All incidents are now reviewed by multidisciplinary panels comprising representatives from across the organisation, facilitating a comprehensive and collaborative review process.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate a dedicated administrator to each house so care staff can focus on caregiving.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory training on monitoring, observation, and one-to-one care requirements.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a modified escalation procedure enabling families to request a second opinion or further care review.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use standardised, structured shift handovers with tools, relevant meeting updates, and regular audits.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a 24-hour floating staff role to supply additional care and supervision when needed.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct and systematically review routine overnight clinical care and observation audits.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene a multi-agency Risk Summit to improve specialist NHS access and review monitoring and observation policies.
Verbatim wording from the response “• Risk Summit: In November 2024, we convened a Risk Summit involving NHS England, regulatory bodies, health and social care partners, and commissioners. This summit” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement communication protocols for promptly and transparently sharing serious care or safeguarding concerns with families and local authorities.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply internal governance oversight to externally commissioned investigations and scrutinise their findings.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a revised incident management policy and process based on national best practice.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a monthly senior-leader Family Forum, document themes, and monitor agreed actions.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed an evidence-based staffing model aligned with national standards and individual children’s needs.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require one-to-one carers to confirm care requirements and obtain approval before stepping away or ending shifts.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain 24-hour on-site clinical oversight through a Clinical Site Manager.
Verbatim wording from the response “• 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.” Source location Response from The Children’s Trust
Open published response
14 Oct 2024 Mia Louise Gauci-Lamport · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Lack of specialist NHS paediatric neuro-consultant oversight View source Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records View source Failure to undertake regular Paediatric Early Warning Score assessments View source Deficiencies in ongoing staff training View source Deficient clinical governance of management and investigation View source Failure to conduct regular audits of clinical practice View source Failure to provide sufficiently frequent direct night-time visual observations View source Failure to ensure robust procedures are in place View source Delays in fulfilling Duty of Candour obligations View source Failure to undertake regular multidisciplinary clinical reviews View source Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Implement and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Conduct regular audits of care quality, care-plan adherence, and monitoring effectiveness under internal and external scrutiny.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Strengthen NHS integration, referral pathways, and coordination with primary, secondary, and tertiary services for timely specialist care.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Reduce reliance on private consultants by integrating ongoing specialist care, including epilepsy management, within NHS services.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Audit medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Review and improve the internal multidisciplinary care model across medical, nursing, care, and therapy services alongside broader NHS integration.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Refine the clinical governance structure and strengthen leadership oversight of care practices, protocols, and improvement implementation.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 October 2024. View source
Action
Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Stated completedThe respondent said that this action was complete when they made their response on 14 October 2024. View source
Action
Complete the thematic review of serious incidents and near misses and embed resulting quality-improvement workstreams in governance arrangements.
Status at responseThe respondent said that this action was partly complete when they made their response on 14 October 2024. View source See 9 more actions
×
AI-generated summary
Mia Louise Gauci-Lamport · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist NHS paediatric neuro-consultant oversight
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented .
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake regular Paediatric Early Warning Score assessments
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ongoing staff training
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training , ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Deficient clinical governance of management and investigation
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death , delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct regular audits of clinical practice
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice . These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently frequent direct night-time visual observations
Wider context from the report “1. Lack of appropriate monitoring of Mia during the night :
Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified . Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure robust procedures are in place
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in fulfilling Duty of Candour obligations
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations , ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake regular multidisciplinary clinical reviews
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs .
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Verbatim wording from the response “○ Individualised Care Plans: We have made certain that care plans are clear, individualised, and regularly updated based on the child’s current needs and challenges and aligned to the PEWS (Paediatric Early Warning Scores). These updates ensure that the monitoring of children is consistent, personalised, and aligned with the latest clinical guidelines. This initial work is complete and is now continuously reviewed and audited in line with our policy and best practice.” Source location Response from The Children's Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.
Verbatim wording from the response “○ Shift Handover Protocol: A revised Shift Handover Protocol has been introduced to ensure that the level of supervision and observation required for each child is understood and clearly communicated during shift changes. Additionally, the last set of clinical observations from the prior shift are recorded and discussed at handover, ensuring a seamless transition and continuity of care. This protocol has been embedded across The Children’s Trust and is subject to continuous review and audit to ensure compliance.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.
Verbatim wording from the response “A comprehensive review of our monitoring protocols and individualised care planning process has been undertaken which has led to several critical actions being identified, all of which are now overseen by robust internal governance:” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular audits of care quality, care-plan adherence, and monitoring effectiveness under internal and external scrutiny.
Verbatim wording from the response “○ Regular Audits and Reviews: To support sustained improvement, we have introduced regular audits to assess the quality of care, the implementation of and adherence to care plans, and the effectiveness of our monitoring practices. This work continues and is scrutinised both internally and by our external regulators and commissioners.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen NHS integration, referral pathways, and coordination with primary, secondary, and tertiary services for timely specialist care.
Verbatim wording from the response “○ Enhanced NHS Integration: The Children’s Trust is actively working with primary, secondary and tertiary NHS services to ensure that children in our care receive timely and regular access to care. We are working with the wider health and social care system to formalise clearer referral pathways and improving coordination with NHS specialists to ensure that all clinical needs are addressed promptly. This work has commenced and continues through existing NHS governance frameworks.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce reliance on private consultants by integrating ongoing specialist care, including epilepsy management, within NHS services.
Verbatim wording from the response “○ Reducing Reliance on Private Consultants: We are actively reducing our reliance on private consultants for ongoing care, particularly in areas such as epilepsy management, and are working to ensure that children receive care that is fully integrated within the NHS. We have required wider health and social care system support to ensure equitable access for the children and young people in our care and this work continues.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.
Verbatim wording from the response “○ Monitoring Tools: A review of monitoring tools, including video surveillance and wearable sensors, has been completed. We continually ensure that these tools are appropriate for each child's needs and used correctly to provide effective oversight without replacing appropriate checks. This initial action is complete and is now continuously reviewed and audited in line with evidence-based practice.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
Verbatim wording from the response “○ Medical records: We continually audit our medical records in line with NHS standards and achieve high compliance against these. As an organisation sitting outside the NHS, health record integration is complex and an ongoing area of focus for us with our wider health and social care system partners. Medical record audits continue regularly to ensure our ongoing compliance in this area.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve the internal multidisciplinary care model across medical, nursing, care, and therapy services alongside broader NHS integration.
Verbatim wording from the response “○ Multi-disciplinary Care Model: We are working with the broader NHS system to improve integration across the whole care pathway and ensure that this is multi-disciplinary across medical, nursing and care and therapy, and not focussed solely on the medical care for the children and young people. Whilst we have a strong internal multi-disciplinary care model focussed around the care of the children, we have also taken the opportunity to commence a detailed review of our internal model alongside broader integration.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refine the clinical governance structure and strengthen leadership oversight of care practices, protocols, and improvement implementation.
Verbatim wording from the response “The Children’s Trust is committed to maintaining and improving robust governance and oversight systems. We have initiated a series of improvements:” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Verbatim wording from the response “○ Frequency of Monitoring and PEWS Practice Audits: We have implemented new Frequency of Monitoring Practice audits overnight, conducted by Clinical Site Managers. This ensures continued compliance with the monitoring and observations policies. These audits are complemented by monthly quality walks to ensure the consistent implementation of care plans and protocols. This additional assurance mechanism is built into roles and responsibilities and findings from these audits feed into the broader clinical governance framework.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the thematic review of serious incidents and near misses and embed resulting quality-improvement workstreams in governance arrangements.
Verbatim wording from the response “• Thematic review: We have undertaken a thematic review of all serious incidents and near misses within a specific timeframe. The themes and trends identified through this review have resulted in dedicated workstreams being embedded into the existing governance structure. The thematic review is currently in the final stages of completion and has focussed on the embedding of continuous quality improvements.” Source location Response from The Children's Trust
Open published response
15 May 2022 Connor Samuel Timothy Wellsted · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Lack of guidance on placement of padded cot boards View source Delayed and incomplete serious incident investigations View source Failure to fully inform forensic pathology experts about relevant equipment involvement in a death View source Failure to accept and embed institutional learning from serious incidents View source Failure to preserve the scene and fully inform police and coronial investigators after a death View source Lack of regular direct visual supervision during the night View source Failure to inform the autopsy pathologist of the circumstances of a death View source Lack of openness, transparency and proper investigation of deaths View source Failure to provide yearly servicing of allocated cots View source Failure to provide accurate information to the CQC about a death View source Failure to undertake prompt internal enquiries after sudden unexpected deaths View source Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths View source Failure to retain medical records after sudden unexpected deaths View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 14
Action
Establish clinical-assets governance, appoint a dedicated clinical-assets lead and assign responsibility for safe deployment, registration, servicing and maintenance.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Review and revise sleep-monitoring procedures, requiring individual risk assessments, documented care-plan monitoring and escalation according to clinical need.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Introduce a mandatory 24-hour sleep-monitoring and equipment-safety chart, with nursing guidance and countersignature requirements.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Provide clinical-assets training through competency assessments, moving-and-handling programmes, therapy training and practice learning, with additional manufacturer training arranged where needed.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Update the Medical Devices and Equipment Policy and keep it aligned with current regulations and best practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022. View source
Action
Establish a learning action group, overseen by the Clinical Governance and Safeguarding Committee, to develop processes and systems addressing the coroner’s concerns.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Stop using the cot type allocated to Connor and replace existing beds and cots with models conforming to BS EN 50637:2017.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Audit compliance with sleep-monitoring risk assessments, care-plan controls and documented checks quarterly.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Transfer clinical-assets and maintenance records to the centralised CATi system and validate bed condition and service-history data.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Maintain contracted inspection, repair and preventive-maintenance arrangements for medical equipment, with monthly KPI monitoring of servicing compliance.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source
Action
Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
Stated plannedThe respondent said that this action was planned when they made their response on 17 May 2022. View source
Action
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022. View source
Action
Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2022. View source See 11 more actions
×
AI-generated summary
Connor Samuel Timothy Wellsted · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on placement of padded cot boards
Wider context from the report “1. The cot
The cot Connor’s was allocated was nine years old, used infrequently and had not had a yearly servicing for the previous five years. There was no guidance or clarity as to how the padded boards/cot bumper should have been placed around the wooden frame of the cot in circumstances whereby the foster parents did not wish the cot to be padded.
It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor across his neck.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed and incomplete serious incident investigations
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully inform forensic pathology experts about relevant equipment involvement in a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death .
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accept and embed institutional learning from serious incidents
Wider context from the report “4. Senior management, Children’s Trust, Tadworth
The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died, or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust .
As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve the scene and fully inform police and coronial investigators after a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular direct visual supervision during the night
Wider context from the report “2. Monitoring of Connor during the night:
Connor had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell) despite the request of his foster parent to check in circumstances whereby in other parts of the Trust regular visual inspection was the norm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the autopsy pathologist of the circumstances of a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of openness, transparency and proper investigation of deaths
Wider context from the report “4. Senior management, Children’s Trust, Tadworth
The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died , or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust.
As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide yearly servicing of allocated cots
Wider context from the report “1. The cot
The cot Connor’s was allocated was nine years old, used infrequently and had not had a yearly servicing for the previous five years . There was no guidance or clarity as to how the padded boards/cot bumper should have been placed around the wooden frame of the cot in circumstances whereby the foster parents did not wish the cot to be padded.
It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor across his neck.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information to the CQC about a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death .
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake prompt internal enquiries after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Children's Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain medical records after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish clinical-assets governance, appoint a dedicated clinical-assets lead and assign responsibility for safe deployment, registration, servicing and maintenance.
Verbatim wording from the response “We commissioned Croydon Healthcare Services to undertake an external review of all our clinical assets inventory and service and maintenance data in January 2019 and entered into a medical equipment maintenance service level agreement with Croydon Healthcare Services in February 2019. Around the same time, we established a new, clinical assets working party meeting, chaired by the director of clinical services, with responsibility for developing and monitoring effective governance arrangements, policies and procedures for the safe deployment of all medical devices. In May 2020 we appointed a dedicated clinical assets lead, responsible for maintaining the clinical assets register and coordinating and overseeing servicing and maintenance in line with statutory requirements and manufacturers’ guidance.” Source location Response from The Children's Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise sleep-monitoring procedures, requiring individual risk assessments, documented care-plan monitoring and escalation according to clinical need.
Verbatim wording from the response “Overnight monitoring policy
As detailed in the evidence of our medical director at the inquest, following Connor’s death, our sleep monitoring procedures were reviewed and revised immediately, to ensure the safety and wellbeing of the children in our care during sleep.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a mandatory 24-hour sleep-monitoring and equipment-safety chart, with nursing guidance and countersignature requirements.
Verbatim wording from the response “Record keeping
We acknowledge that at the time of Connor’s death, we did not have robust record-keeping in place to evidence overnight monitoring checks. We have addressed this by introducing a 24-hour sleep monitoring chart that must be completed for each child every day. The chart documents the time” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinical-assets training through competency assessments, moving-and-handling programmes, therapy training and practice learning, with additional manufacturer training arranged where needed.
Verbatim wording from the response “Staff are trained in the appropriate use of clinical assets in a number of ways including through our existing clinical competencies assessments and moving and handling training programmes; as part of “therapy training days” and “in practice learning”. Nursing and care staff are also required to familiarise themselves with individual care plans which contain guidance, including photographs, on the use of specific clinical assets assigned to each child or young person.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
Verbatim wording from the response “We accept that we should have thoroughly examined the potential role of the cot bumper in our initial investigation. With hindsight we were too quick to rule the bumper out based on the post-mortem findings. Our learnings here are reflected in the updates we have since made to our “Incident Reporting and Investigation, including Duty of Candour Policy”.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Medical Devices and Equipment Policy and keep it aligned with current regulations and best practice.
Verbatim wording from the response “Policies, procedures, training and guidance for staff
As detailed in the evidence of our current medical director at the inquest, as part of the learning following Connor’s death, we have updated our Medical Devices and Equipment Policy and keep this under review to ensure it is aligned with current regulations and best practice.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a learning action group, overseen by the Clinical Governance and Safeguarding Committee, to develop processes and systems addressing the coroner’s concerns.
Verbatim wording from the response “Our senior leadership team, with the full involvement of our board of trustees, has established a learning action group (overseen by our Clinical Governance & Safeguarding Committee) dedicated to developing new processes and systems that will address the coroner’s concerns and will build upon the improvements we have been making over the last five years.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stop using the cot type allocated to Connor and replace existing beds and cots with models conforming to BS EN 50637:2017.
Verbatim wording from the response “Type of cot
During the course of the inquest into Connor’s death, the coroner heard evidence from the former director of clinical services (chief nurse), and the current medical director of The Children’s Trust, in respect of the measures we have implemented to ensure the safety of sleeping equipment. We stopped using the specific type of cot allocated to Connor in October 2017. All our bed supports and sleeping systems are assessed and recommended by qualified practitioners.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with sleep-monitoring risk assessments, care-plan controls and documented checks quarterly.
Verbatim wording from the response “Compliance monitoring
Compliance with the Sleep Monitoring Policy is assessed through quarterly audits by nursing and care staff of a selection of clinical records. The audits look for evidence of i) risk assessments having been completed appropriately, ii) control measures identified to manage the risks having been incorporated into the care plan and iii) those control measures having been adhered to and documented in the 24-hour evaluation chart. The most recent audits in September 2021 and January 2022, respectively reported 99.4% and 98.1% compliance, respectively.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer clinical-assets and maintenance records to the centralised CATi system and validate bed condition and service-history data.
Verbatim wording from the response “In October 2020, we transferred our Excel-based clinical assets register and maintenance records to a new centralised system, “CATi”. As part of this project, we completed a “desk-top bed audit” followed by a physical inspection and a validation of service history data. A bed condition report was completed and reviewed by the Clinical Governance & Safeguarding Committee.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain contracted inspection, repair and preventive-maintenance arrangements for medical equipment, with monthly KPI monitoring of servicing compliance.
Verbatim wording from the response “Servicing and maintenance, governance and record keeping
We have contracts in place with two UK-based, bio-medical engineering, repair and maintenance companies who carry out regular inspections of medical equipment and devices and undertake repairs and preventive maintenance. Our estates compliance team monitors a number of KPIs on a monthly basis to provide assurance that beds and other clinical assets have been serviced in line with the relevant servicing schedule. Compliance has averaged 99% over the last quarter.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
Verbatim wording from the response “In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Verbatim wording from the response “In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.” Source location Response from The Children's Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
Verbatim wording from the response “Our Basic Life Support (BLS) training follows the Resuscitation Council UK guidelines and is mandatory for all nursing and care staff. Shift leaders and senior nurses also attend an enhanced BLS+ training annually which is designed to increase knowledge, skills and confidence in managing medical emergencies. It further emphasises and builds upon the Resuscitation Council UK guidelines taught in BLS and includes enhanced simulations and training around escalation of care and management of medical emergencies more relevant to our service. Additionally, the training covers how to call for help, using the bleep system, using call bells, dialling 999 and at what point each might be appropriate. Each BLS session ends with a mandatory assessment of skills.” Source location Response from The Children's Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Connor’s equipment and room remained sealed after staff repositioned him for clinical assessment, contrary to the concern that the scene was not preserved.
Verbatim wording from the response “airway, check for breathing, and check circulation. Accordingly, when our staff first found Connor unresponsive in his cot, they moved him into a horizontal, supine position in order to assess his vital signs. The police then performed their own independent physical examination. All of Connor’s equipment remained in the room with him, and the room (including the bed and bumpers) remained sealed until the findings of the post-mortem were released.” Source location Response from The Children's Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The statutory notification described Connor’s position, the cot bumper and emergency assessment, although it inaccurately reported the overnight checking frequency.
Verbatim wording from the response “Our former head of nursing and care formally notified the CQC of Connor’s death via their online statutory notification system on the 17th May 2017, the day of Connor’s death. The notification clearly stated the position he was found in, the position of the cot bumper ‘across his chest area’ and the emergency “ABC” assessment performed. In this notification we did incorrectly advise that Connor had been checked every 15 minutes overnight. However, once the medical notes were returned from the Coroner’s Office in November 2017 and we could begin our investigation, we realised our error. We contacted the CQC on 29th November 2017 explaining the sleep monitoring arrangements that had in fact been in place for Connor. The CQC has confirmed they have a record of this call and have provided us with the transcript.” Source location Response from The Children's Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk-assessed overnight monitoring, documented care plans, audiovisual observation and compliance audits are considered sufficient rather than requiring uniform direct visual checks.
Verbatim wording from the response “Visual Surveillance
As outlined in the Sleep Monitoring Policy, the minimum required level of visual surveillance includes entering the bedroom and physically observing and assessing a child to ensure they are sleeping soundly, are not tangled in any bedding, are comfortable and not in distress. If a parent or carer would prefer that a medically stable child should not be disturbed overnight then this is risk assessed and, as a minimum, an audio-visual monitor would be used to allow remote observation. The frequency of monitoring overnight is clearly documented in every child’s care plan and must be signed by the parent/carer and a registered nurse.” Source location Response from The Children's Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The police were informed of the cot bumper’s position and the relevant timing and circumstances of death were recorded in investigative materials.
Verbatim wording from the response “Information provided to the police and coroner’s service
We willingly complied with all external investigations that took place and also carried out our own detailed review. The evidence before the coroner at the inquest was that the police officer attending the scene following Connor’s death had been informed of the position in which the cot bumper had been found. This was reflected in the contemporaneous notes taken by the officer in their police-issued pocket notebook. The officer in question gave evidence at the inquest that he had been informed of the positioning of the bumper.” Source location Response from The Children's Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current bed systems, qualified assessment, servicing controls and monitoring arrangements are considered robust responses to sleeping-equipment safety concerns.
Verbatim wording from the response “We have put in place extensive measures and improvements over the last five years, and we are confident that these measures are robust and effective. Concerns raised in the regulation 28 report, with regards to the prevention of future deaths, relate to issues we have addressed during the significant passage of time since Connor's death, as heard in evidence at the inquest. The coroner has not raised any concerns about the adequacy of the measures we have put in place. Nevertheless, in the first section of this response we set out the actions we have already taken and summarise the evidence heard at the inquest about the changes implemented from the lessons learnt.” Source location Response from The Children's Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations