Mia’s inquest – Louise Richer, Bracknell Forest

The court heard from four witnesses in person on Day 1 of Mia’s inquest, on Tuesday 30 July. The first witness was Lou Richer. She told the court that she is the Head of Children’s Specialist Safeguarding for Bracknell Forest Council and that she’d worked in the Specialist Support Service for 10.5 years and known Mia for all of that time. She had previously been the team manager and she said that she had lots of involvement with Mia’s case and she “knew Mia as well as any social work manager can”.

The coroner thanked Ms Richer for her statement which she said had been extremely helpful. The coroner checked that Mia had her first seizure at 1 year and 5 months, which Ms Richer confirmed was the case “according to my records” and confirmed that Mia was diagnosed with Ohtahara Syndrome in September 2017, 11 years later.

Asked for a reason why it took so long for Mia to receive a diagnosis, Ms Richer responded:

LR: To my knowledge I think Mia was a neurotypical child for the first few months, and early years, first year and a bit, then her presentation altered, it became apparent she had significant needs and disabilities

She told the court that Mia had lots of investigations over the years before she was finally diagnosed. Ms Richer said that support, as is often the case for a child with complex needs, was built up over time. When very young it was a case of Occupational Therapy and equipment, but as children get older there is the need for respite services, and working with health partners to support Mia and her family.

She said that Mia became a looked-after child and by 2018 she had an Education Health and Care Plan (EHCP). The coroner asked her to explain what an EHCP was and she did.

Mia’s plan brought together the needs she had in one place really, in one document, so her Education, Health and Care needs could be identified and people working with Mia could work out how to meet those needs.

The court heard that Mia became progressively more unwell and her needs became more profound over time. In June 2018 Mia’s health was very unstable and she had a number of admissions to hospital. A decision was made in February 2020 that Mia needed full time residential care, to meet her needs.

Ms Richer said that they worked with Mia’s family to find a placement suitable to her, after she had been placed in a short break service in Bracknell. The coroner asked Ms Richer to explain what care Mia needed when she eventually had a place at The Children’s Trust, Tadworth.

Mia needed round the clock care with every aspect of her life and wellbeing, she hadn’t been accessing school for quite some time before being placed at The Children’s Trust…. We liked Children’s Trust as it allowed all her needs to be met in one place, health, care and education in one setting.

Ms Richer said Mia needed significant support to access education, and with activities of daily living such as feeding and cleaning herself. She also told the court that Mia was a very social child who liked to people watch and engage with people.

Ms Richer said that there were three reasons why they chose The Children’s Trust, Tadworth for Mia.

1) Quality of placement

She said The Children’s Trust was “recognised as a very good placement, had an outstanding Ofsted at that time”.

2) School on site

She said it also had a school attached to it “we were able to place Mia where all her needs were met in one place”.

3) Relatively local to Bracknell

Ms Richer said that this was really important. “We always want children to be as close to home as possible… it enabled Mia to maintain important relationships with her family”.

Ms Richer said that the plan had been that Mia would remain at The Children’s Trust until she was at least 18. Mia had a structured transition plan and moved from Larchwood to Camelia House at The Children’s Trust in July 2020. Then in November 2022 Mia was moved to Jasmine House. Asked about that move Ms Richer told the coroner that it was thought Jasmine House would be a more appropriate environment for Mia because of the other young people in that setting, it was more likely that she would be able to access social opportunities that were important to her, and it was a more appropriate peer group.

The coroner explored the balance of the relationship between Bracknell Forest, who she described as responsible for Mia’s care, and The Children’s Trust, who were responsible for care plans. She asked what the balance was and where it lay.

Ms Richer told the court that all looked after children have a careplan that links to the EHCP and “pulls together the child’s needs in a range of different areas”.

LR: When we place children in placements such as The Children’s Trust, where clinical expertise is on site, the detailed care planning of how clinical and medical needs are met is done by the placement, family of course, the young person and the placing authority. Detail is within her Children’s Trust care plans, but her overarching care plan was her Looked After Child Care Plan.

C: You have ultimate responsibility, but you delegate?

LR: Exactly that

The coroner explored what assessment the council make to ensure the care is satisfactory. Ms Richer said that they only choose providers that the regulator has said are of reasonable quality, not generally placing people with any providers that require improvement or are inadequate. She said this provider had an outstanding Ofsted [they are no longer rated outstanding, they are now good], that they conducted due diligence and have a commissioning team “who review and check that all the policies we’d expect in place, are in place”.

There was some discussion about the frequency of visits from Mia’s allocated social worker, Catherine Lloyd. Ms Richer said Mia’s social worker visited her very regularly “in line with statutory timescales, sometimes in excess of that”.

C: There is a balance isn’t there. What did you understand, I appreciate you’re not medical, what did you understand about Mia’s medical needs, particularly her epilepsy?

LR: What I understood as Head of Service, as a local authority, was Mia was placed somewhere with significant expertise with regards epilepsy and her care plan would reflect the needs she had…. Medication regime, emergency response to seizures, how frequently she needs to be observed and checked, and things that might trigger her seizures

The coroner observed that there was a “very holistic programme” for Mia, which Ms Richer agreed. She confirmed that Mia’s social worker visited every six weeks.

C: Throughout 2021 into 2022 were there any concerns raised to you, by you, or your team with regard to the care Mia was receiving at Tadworth?

LR: No significant concerns, reasonable to say that… were occasions where Catherine visited and came back, would use supervision to reflect on experiences of children visited… occasion where Catherine felt staff didn’t know she was coming, proceeded with taking Mia for a bath when Catherine needed to spend time with her.

Occasions where we felt Mia was perhaps not stimulated enough in placement as we’d like, but not regular…. Many occasions Mia would present as happy and settled, where there were concerns we would follow up with Children’s Trust, we always felt the response was appropriate.

There was an occasion where a request was made for a fee uplift, it was unclear what that was about… the Commissioning Team identified The Children’s Trust were having financial challenges, so we met with them to explore that.

Other than those things, we were generally satisfied with the care Mia received.

C: So although there were some issues, they were dealt with… didn’t feel any adverse care was being provided?

LR: No. If we’d felt adverse care was being provided we’d have taken action to address that.

Ms Richer told the court about a two day visit that Catherine conducted, to try to get to understand Mia’s daily experience at The Children’s Trust.

C: What was your understanding of her recall of that?

LR: All children we look after, whether they are a Looked After Child or not, we try to do all we can to understand their lived experience… when [a child is] non-verbal we undertake day in the life of over one long day or two half days… enables social worker to take in a piece of work and really understand what life looks like for that child, from when wake up in morning to when they go to bed at night.

Catherine did this over 2 days which gave a really clear understanding of her experience… generally felt Mia had really positive experience of life at The Children’s Trust, some minor recommendations were made, I’m struggling to recall what they were, some things, but nothing so significant that it springs to mind, overall the care was good.

C: Thank you very much indeed.

The coroner then discussed a couple of visits by the social worker where concerns were noted, such as increased seizure activity in April 2023, and Mia’s Neater Eater not being used. Ms Richer confirmed that these matters were raised with The Children’s Trust.

The coroner asked Ms Richer to tell the court of what happens when a Looked After Child dies unexpectedly. She explained the process, noting fortunately it happens very rarely. She said that there were a number of formal notifications that had to be done, including notifying the local Safeguarding Board, although it was Surrey Safeguarding Board who undertook an investigation because Mia was placed in Surrey.

C: That’s what you have to do. You’ve raised some concerns with the understanding of Tadworth by Mia’s death. Could you bring them to courts attention.

LR: What happened initially was there was an initial meeting, I forget the name, an initial meeting after a child’s death ….

C : Rapid Review?

LR: Yes, Rapid Review, within the Rapid Review process, there was a few things that left me feeling curious, potential discrepancies within the time taken to call an ambulance. Also concerned when Mia was found by staff at The Children’s Trust she was reported to be cyanosed, efforts made to use defibrillator, no shockable rhythm at that point.

I’m not a doctor but that left me wondering about Mia’s time of death, and whether that had perhaps been some time before.

Discussions of what the Police found at the scene in the Rapid Review process, was a question mark over the pillow in Mia’s bed. Police reported it was not a sleep safe pillow in Mia’s bed. Discussion about that being put in after the event. I understand in attempts to resuscitate Mia she was moved from the bed… and those were things I was curious about…

C: So the exact time Mia was found unresponsive. Staff told attending Police Officers [she had been checked] at 06:00. Reported manager said found 06:20 having been previously checked 06:10.

Emergency Department Report states call at 06:39, even though staff said they made it at 06:20. So there was some confusion as to when Mia was found, and when emergency services were called?

LR: Correct

C: A potential delay of 19 minutes at a point at which Mia was found unresponsive.

Just to confirm Tadworth Report reported the call was made at 06:20 and that’s incorrect, SECAMB [South East Coast Ambulance Service] report noted the call at 06:39.

Surrey Police noted sleep safe pillow to be on the floor, cylinder shaped pillow in her bed?

LR: Yes

C: Were you able to resolve any of these timing issues or pillow issues in your investigation?

LR: No, there remained some confusion and uncertainty around those timing issues…. Why we identified there needed to be a further full investigation.

The coroner then discussed with Ms Richer the National Child Safeguarding Practice Review Panel work around safeguarding children with complex health needs, following the abuse and neglect of children in residential settings in Doncaster. Ms Richer explained this was a national review, not specific to Mia, but she was one of the children who they undertook a review with regards to their responsibility.

LR: That review concluded we had no significant concerns in relation to Mia’s care. We felt her care was good.

C: Other than the events of 10, 11 September?

LR: Yes, but that review took place before we sadly lost Mia

C: Thank you. You’ve also written about lessons learned…. Following on from Mia’s death what has happened within your service?

LR: We obviously raised the concerns about the discrepancies and what had happened to Mia within our care governance process. We will continue to review our placements at The Children’s Trust. We don’t have any other placements there, we haven’t had a child placed there, also not had a child with needs as complex as Mia…. Children’s Trust is a fairly unique provider … following up through our care governance process, then will continue to review. The outcome of this inquest will be important to us with regards moving forward and placements at The Children’s Trust.

There were no questions from Mia’s family, from The Children’s Trust or from Bracknell Forest for Ms Richer. The coroner thanked her for her attendance and evidence and released her from oath telling her that she was free to leave the court or stay if she wished. She said that she would be staying.

Court then adjourned for a short mid morning break.

One comment on “Mia’s inquest – Louise Richer, Bracknell Forest”

Write a reply or comment

Your email address will not be published. Required fields are marked *

*