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Investigation and inquest
From 7th April to 9th April 2025 evidence was heard touching the death of Raihana Oluwamidalo Awolaja. She had died on the 1st June 2023 aged 12 years at St George’s Hospital, Blackshaw Road, Tooting, London. She had died after she had been left unsupervised in her residential care home, The Children’s Trust, Tadworth Court, for approximately fifteen minutes, despite being on one-to-one care for tracheostomy care and other medical conditions and disabilities. Her tracheostomy tube was blocked by secretions and as no carer was present to clear it, she suffered respiratory compromise and arrested. She was resuscitated at the scene but later died of hypoxic brain injury.
Medical Cause of Death
1 a. Hypoxic ischaemic brain injury
1b Cardiac arrest
1c Post viral respiratory secretions
II Pneumonia
How, when, where and in what circumstances the deceased came by her death:
Raihana had been born prematurely at only 27 weeks gestation and as such suffered with significant medical illnesses and disabilities. She was tracheostomy dependent for breathing. She was resident at the Children’s Trust (TCT) where she should have received one to one nursing care to safeguard her tracheostomy.
She had recently suffered viral pneumonia requiring ventilation on PICU and was discharged back to TCT on 23rd May 2023. She was recovering from the pneumonia but still had some increased respiratory secretions requiring an increase in nebulisation therapy and increasing her respiratory vulnerability.
On 29/5/2023 her allocated carer left the unit to undertake an administrative task at 19:25-19:30, handing over her nursing care to a nurse due to go off shift. At approximately 19:35, this nurse in turn handed over to another nurse (nurse two) as her shift had ended. Nurse two did not supervise Raihana, instead was caring for another child.
At approximately 19:50 Raihana’s allocated nurse returned to find that Raihanna had arrested. The alarm was raised, CPR started, and an ambulance called. A return of circulation was achieved at 20:26 and Raihana was transferred to St George’s Hospital. Sadly, she died of hypoxic ischaemic brain injury at 19:34 hours on 01/06/2023. Her arrest had been caused by secretions partially blocking her tracheostomy tube.
If she had been appropriately observed between 19:35 and 19:50 this would have been recognised and resolved and on the balance of probabilities she would not have died at this time. This failure to adequately observe her was a gross failure in care by the nursing staff.
This was compounded by the lack of sufficient staff on the unit where Raihana lived to provide proper 1:1 care.
Final Conclusion:
Natural Causes Contributed to by neglect.
Circumstances of the death
Raihana had been born prematurely at only 27 weeks gestation and as such suffered with significant medical illnesses and disabilities. She was tracheostomy dependent for breathing. She was resident at the Children’s Trust (TCT) where she should have received one to one nursing care to safeguard her tracheostomy.
She had recently suffered viral pneumonia requiring ventilation on PICU and was discharged back to TCT on 23rd May 2023. She was recovering from the pneumonia but still had some increased respiratory secretions requiring an increase in nebulisation therapy and increasing her respiratory vulnerability.
On 29/5/2023 her allocated carer left the unit to undertake an administrative task at 19:25-19:30, handing over her nursing care to a nurse due to go off shift. At approximately 19:35, this nurse in turn handed over to another nurse (nurse two) as her shift had ended. Nurse two did not supervise Raihana, instead was caring for another child.
At approximately 19:50 Raihana’s allocated nurse returned to find that Raihanna had arrested. The alarm was raised, CPR started, and an ambulance called. A return of circulation was achieved at 20:26 and Raihana was transferred to St George’s Hospital. Sadly, she died of hypoxic ischaemic brain injury at 19:34 hours on 01/06/2023. Her arrest had been caused by secretions partially blocking her tracheostomy tube.
If she had been appropriately observed between 19:35 and 19:50 this would have been recognised and resolved and on the balance of probabilities she would not have died at this time. This failure to adequately observe her was a gross failure in care by the nursing staff.
This was compounded by the lack of sufficient staff on the unit where Raihana lived to provide proper 1:1 care.
Final Conclusion:
Natural Causes Contributed to by neglect.
Coroner’s concerns
1. That children such as Raihana requiring one to one care are still at times receiving less intensive care and supervision than they require.
2. That there may be culture of cover up at the TCT, in that they carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths.
3. That TCT do not sufficiently communicate with the commissioning LA nor next of kin in relation to issues with care and supervision, for example not informing the named social worker nor the mother of the disciplinary proceedings against a staff member who left Raihana alone. This in turn leaves vulnerable residents at risk, as the named social workers and possibly the commissioning authority nor the next of kin will be aware of potential increased risks to the vulnerable child. This matter also goes to matter 2 above.
4. That there may be staff training issues in relation to what one to one care means in practice.
5. That there may be training issues in relation to the prioritisation of administrative tasks above care.
6. That next of kin are not sufficiently listened to when they raise concerns, and their complaints are dismissed without sufficient investigation.
7. That the systems of communication between those attending planning and review meetings and those providing care to the residents are inadequate, such that matters raised at these meetings and any actions agreed to address them are insufficiently communicated to those providing care to the residents.
Information checked against the published report and official responses