Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 28
Care Quality Commission Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.
View source
Care Quality Commission Continue monitoring and inspecting according to the published methodology, responding to emerging risks identified through notifications or whistleblowing reports.
View source
Care Quality Commission Conduct comprehensive and targeted inspections of The Children’s Trust, including reviews of audits, records, care-plan adherence and safety practices.
View source
NHS England Continue monitoring the Children’s Trust’s outstanding improvement actions through NHS England South East.
View source
NHS England Share the Report with the NHS England Regulation 28 Working Group and regional mortality working groups, including Integrated Care Systems.
View source
NHS England Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
View source
NHS England Ensure relevant NHS England policy teams are aware of the Report and its concerns.
View source
NHS England Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
View source
NHS England Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS structures.
View source
The Children's Trust Establish clinical-assets governance, appoint a dedicated clinical-assets lead and assign responsibility for safe deployment, registration, servicing and maintenance.
View source
The Children's Trust Review and revise sleep-monitoring procedures, requiring individual risk assessments, documented care-plan monitoring and escalation according to clinical need.
View source
The Children's Trust Introduce a mandatory 24-hour sleep-monitoring and equipment-safety chart, with nursing guidance and countersignature requirements.
View source
The Children's Trust Require faulty equipment to be reported immediately, removed from service and repaired or replaced, with larger items tagged and removed from rooms.
View source
The Children's Trust Provide clinical-assets training through competency assessments, moving-and-handling programmes, therapy training and practice learning, with additional manufacturer training arranged where needed.
View source
The Children's Trust Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
View source
The Children's Trust Require qualified practitioners to assess and recommend all bed supports and sleeping systems.
View source
The Children's Trust Require and quarterly-audit twice-daily documented safety checks of beds, cots, bumpers and other equipment.
View source
The Children's Trust Update the Medical Devices and Equipment Policy and keep it aligned with current regulations and best practice.
View source
The Children's Trust Establish a learning action group, overseen by the Clinical Governance and Safeguarding Committee, to develop processes and systems addressing the coroner’s concerns.
View source
The Children's Trust Stop using the cot type allocated to Connor and replace existing beds and cots with models conforming to BS EN 50637:2017.
View source
The Children's Trust Audit compliance with sleep-monitoring risk assessments, care-plan controls and documented checks quarterly.
View source
The Children's Trust Transfer clinical-assets and maintenance records to the centralised CATi system and validate bed condition and service-history data.
View source
The Children's Trust Expand and rename the Sleep Monitoring Policy to cover required monitoring throughout the 24-hour period.
View source
The Children's Trust Maintain contracted inspection, repair and preventive-maintenance arrangements for medical equipment, with monthly KPI monitoring of servicing compliance.
View source
The Children's Trust Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
View source
The Children's Trust Require qualified registered professionals to risk-assess specialist equipment before use.
View source
The Children's Trust Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
View source
The Children's Trust Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
View source Respondent positions A position is what a recipient says about a concern when it does not describe a specific action. 12
Care Quality Commission There was no clinical indication for overnight observations because the child was assessed as physically and medically well on admission.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Care Quality Commission Overnight monitoring is adequately governed by an individualised policy requiring monitoring according to each child’s clinical need.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Care Quality Commission Replacing all specialist cots with equipment compliant with current bed standards addresses the concern about the cot used.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Care Quality Commission Current leadership, governance and practice are considered safe, with no evidence that the reported concerns remain current concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Care Quality Commission The statutory notification described the padded bumper as being against the child’s chest, rather than his neck.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Care Quality Commission Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
NHS England Integrated Care Systems are responsible for providers in their areas and can check adherence to guidance intended to prevent future deaths.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
The Children's Trust Connor’s equipment and room remained sealed after staff repositioned him for clinical assessment, contrary to the concern that the scene was not preserved.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
The Children's Trust The statutory notification described Connor’s position, the cot bumper and emergency assessment, although it inaccurately reported the overnight checking frequency.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
The Children's Trust Risk-assessed overnight monitoring, documented care plans, audiovisual observation and compliance audits are considered sufficient rather than requiring uniform direct visual checks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
The Children's Trust The police were informed of the cot bumper’s position and the relevant timing and circumstances of death were recorded in investigative materials.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
The Children's Trust Current bed systems, qualified assessment, servicing controls and monitoring arrangements are considered robust responses to sleeping-equipment safety concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? Yes — Inadequate safety incident investigations .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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 Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.
Verbatim wording from the response “All statutory notifications received by the CQC from TCT since I became the relationship owner in 2018, have been followed up with appropriate and robust investigation reports, complete with details of actions taken and improvements made.” Source location Response from CQC
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 Continue monitoring and inspecting according to the published methodology, responding to emerging risks identified through notifications or whistleblowing reports.
Verbatim wording from the response “The inspections completed in the five years since Connor’s death, as well as the information available regarding TCT’s response to incidents, events and complaints, have all identified safe practice and good leadership and governance. The CQC have not found any evidence to suggest that the concerns raised in the Regulation 28 report, remain as concerns, regarding current leadership, governance or practice.” Source location Response from CQC
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 comprehensive and targeted inspections of The Children’s Trust, including reviews of audits, records, care-plan adherence and safety practices.
Verbatim wording from the response “The CQC have carried out three inspections of TCT since Connor’s death as follows:” Source location Response from CQC
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 Continue monitoring the Children’s Trust’s outstanding improvement actions through NHS England South East.
Verbatim wording from the response “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.” Source location Response from NHS England
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 Share the Report with the NHS England Regulation 28 Working Group and regional mortality working groups, including Integrated Care Systems.
Verbatim wording from the response “Further, your Report has been shared with the NHSE Regulation 28 Working Group, who in turn have shared the Report with their regions through their mortality working groups, whose membership includes Integrated Care Systems (ICSs). ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. ICSs are responsible for providers within their area and are able to check that they are adhering to guidance which could prevent future deaths.” Source location Response from NHS England
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 Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
Verbatim wording from the response “In terms of investigation, the NHS England Patient Safety Incident Response Framework in July 2022. The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety. The PSIRF is a contractual requirement under the NHS Standard Contract, and as such is mandatory for services provided under that contract and will include Providers such as The Children’s Trust at Tadworth Court.” Source location Response from NHS England
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 Ensure relevant NHS England policy teams are aware of the Report and its concerns.
Verbatim wording from the response “transformation in those areas (such as Specialised Commissioning and the Children and Young People Programme) were aware of this Report and the concerns raised. The team investigating and drafting this response have met with representatives from a variety of teams that cover this domain. We have also ensured that they are aware of the new guidance on beds and cots ‘Bed rails: Management and Safe Use’.” Source location Response from NHS England
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 Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Verbatim wording from the response “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.” Source location Response from NHS England
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 Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS structures.
Verbatim wording from the response “I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Connor, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
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 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
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 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
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 Require faulty equipment to be reported immediately, removed from service and repaired or replaced, with larger items tagged and removed from rooms.
Verbatim wording from the response “Should equipment be identified as faulty, staff are required to report it immediately to the facilities helpdesk using our “Top Desk” reporting system, accessible via our intranet. The equipment in question will immediately be taken out of service for repair or replacement. Larger items will be clearly tagged to state they are “out of use” and moved out of the child or young person’s room, as applicable.” 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 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
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 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
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 Require qualified practitioners to assess and recommend all bed supports and sleeping systems.
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
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 Require and quarterly-audit twice-daily documented safety checks of beds, cots, bumpers and other equipment.
Verbatim wording from the response “It is mandatory for nursing and care staff to carry out and to document checks on beds, cots, bumpers and other equipment twice in every 24-hour period, once during the day shift and once during the night shift. Compliance is monitored through quarterly audits. For the quarter ending January 2022, compliance was assessed as 98.8% (and 98.1% for the previous quarter).” 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 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
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 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
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 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
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 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
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 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
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 Expand and rename the Sleep Monitoring Policy to cover required monitoring throughout the 24-hour period.
Verbatim wording from the response “Our current Sleep Monitoring Policy is due for review in July 2022, in line with our standard policy review cycle. Two changes we will be making to the policy will be to expand its scope and to rename it the ‘Frequency of Monitoring Policy and Procedure.’ These changes will ensure that we incorporate the required monitoring practice over a 24-hour period and not just whilst a child or young person is asleep overnight.” 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 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
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 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
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 Require qualified registered professionals to risk-assess specialist equipment before use.
Verbatim wording from the response “Specialist equipment such as adapted beds, sleep systems, moving and handling devices and seating must be risk assessed by a qualified registered professional before use.” 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 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
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 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
Open published response
×
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 There was no clinical indication for overnight observations because the child was assessed as physically and medically well on admission.
Verbatim wording from the response “The CQC response:
The RCA shared with the CQC states that Connor was not observed overnight when at home and he was assessed by the multi-disciplinary team at TCT on admission, as being physically and medically well. This led to the decision that there was no clinical indication for overnight observations. The needs of the children staying in different parts of TCT vary. For example, Chestnut House cares for children with the most complex of needs, including medical. Connor was placed in Maple House for his rehabilitation and did not have any medical needs at that time.” Source location Response from CQC
Open published response
×
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 Overnight monitoring is adequately governed by an individualised policy requiring monitoring according to each child’s clinical need.
Verbatim wording from the response “TCT have introduced a clear and comprehensive Sleep Monitoring Policy, which was signed off and implemented in 2018 and updated in 2019. The policy has been further updated and renamed Frequency of Monitoring and is due to be signed-off in July 2022. Records reviews during each of the inspections indicated staff understanding of the policy and adherence in children’s care plans where the requirement of overnight monitoring is based on clinical need and individualised to each child.” Source location Response from CQC
Open published response
×
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 Replacing all specialist cots with equipment compliant with current bed standards addresses the concern about the cot used.
Verbatim wording from the response “The CQC response:
The cot used for Connor during this admission was not a standard piece of equipment used by staff at TCT and they were unfamiliar with its use. This type of cot is no longer in use at TCT and all specialist cots have been replaced with equipment compliant with current bed standards. (BS EN 50637:2017 – Medical electrical equipment – Particular requirements for the basic safety and essential performance of medical beds for children).” Source location Response from CQC
Open published response
×
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 leadership, governance and practice are considered safe, with no evidence that the reported concerns remain current concerns.
Verbatim wording from the response “The inspections completed in the five years since Connor’s death, as well as the information available regarding TCT’s response to incidents, events and complaints, have all identified safe practice and good leadership and governance. The CQC have not found any evidence to suggest that the concerns raised in the Regulation 28 report, remain as concerns, regarding current leadership, governance or practice.” Source location Response from CQC
Open published response
×
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 The statutory notification described the padded bumper as being against the child’s chest, rather than his neck.
Verbatim wording from the response “The CQC response:
The statutory notification shared with the CQC on the day Connor died, described his position in the cot and stated that the padded bumper was found against his chest, rather than his neck.” Source location Response from CQC
Open published response
×
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 Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.
Verbatim wording from the response “All statutory notifications received by the CQC from TCT since I became the relationship owner in 2018, have been followed up with appropriate and robust investigation reports, complete with details of actions taken and improvements made.” Source location Response from CQC
Open published response
×
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 Integrated Care Systems are responsible for providers in their areas and can check adherence to guidance intended to prevent future deaths.
Verbatim wording from the response “Further, your Report has been shared with the NHSE Regulation 28 Working Group, who in turn have shared the Report with their regions through their mortality working groups, whose membership includes Integrated Care Systems (ICSs). ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. ICSs are responsible for providers within their area and are able to check that they are adhering to guidance which could prevent future deaths.” Source location Response from NHS England
Open published response
×
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 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
Open published response
×
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 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
Open published response
×
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 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
Open published response
×
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 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
Open published response
×
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
Open published response
Pin
Get email alerts
Request correction
Information checked against the published report and official responses