After lunch on Day 1 the Coroner said that it may be useful, before she called Laura Yapichi to give her evidence, for her to read in part the statement of Emma Dickerson. Emma Dickerson was not in court to give live evidence, as all parties agreed to her evidence, so parts of her statement were read onto the record by the Coroner.

She told the court that Emma Dickerson, began working at The Children’s Trust as a Bank Children’s Support Assistant in June 2020. In September 2022 she received a masters degree in adult nursing and she began her first job as a newly qualified nurse earlier this year, 2024.

Ms Dickerson had worked at Tadworth Children’s Trust for Jasmine House between 1 January and 10 December 2023. Prior to Mia’s death she had worked 13 shifts (in Jasmine House). Ms Dickerson’s statement explained the houses at The Children’s Trust, school houses have children staying in longer placements and the rehabilitation houses have children on shorter term placements. Ms Dickerson told the court that she worked in multiple houses across the site.

She said that typically when she is working with a young person who she does not know well, she would review all sections of their care plan, for longer term patients she was likely to check their baseline observations. She told the court that Mia was a longer term resident at Tadworth and she had reviewed elements of her care plan over time.

She said as she was not allocated to Mia on the 10th or 3rd September she did not recall accessing her care plan on those dates. She told the court that she was aware Mia was at risk of having seizures and she did have them from time to time. Ms Dickerson didn’t recall ever witnessing Mia’s seizures on any of her shifts, since she’d started at The Children’s Trust in June 2020.

Ms Dickerson told the court in her statement that it was common practice recent seizures would be reported at handover and she vaguely recalled being made aware of Mia having a seizure at school. She could not be sure of the date.

Ms Dickerson’s statement continued, that Mia had a wheelchair, a comfy chair, a specialised bed and she could also spend time on the floor on a mat.

She said she had been informed by the Children’s Trust Investigator that Mia’s perforated pillow was an anti suffocation pillow. She told the court that Mia’s careplan “offered one brief sentence on the existence of the pillow, and that it should be used, but no other details or information”. She said that she did not receive any training or guidance on the pillow.

Ms Dickerson said young people at Tadworth have different levels of observations. She said that some were for 15 minute checks, other 30 minutes or more. She said, personally she would “go inside the bedroom and observe and check the child according to the schedule”. She described an A4 sheet, double sided for each child in the house that was used to document their position, the other side being a food or fluid chart.

She said that young people requiring one to one observations were to be continuously observed. She said during night shift the lights in the corridor were often dimmed… to ensure it was light enough for a visual check, Ms Dickerson said she either used a torch or put on a small light in the young person’s bedroom. She said she would not typically turn on the main bedroom light, so as to not disturb a young person’s sleep, but she’d ensure there was enough light for her to conduct her check (as above).

“I was not aware of any specific policies detailing the precise way Tadworth expected staff to complete visual checks. I did not receive any specific training on how to complete these checks”

Ms Dickerson said that she would follow the guidance and example of senior staff or the allocated shift leader.

She then went on to discuss staffing on 10 September. She told the court that each corridor in Jasmine House had one child who required constant one to one observations and three children who required 15 minute checks. She said that on the 10 September one of the children who required 15 minute checks was on home leave.

Ms Dickerson said she was providing one to one support to one child, and Laura Yapichi was allocated the other two young people, Mia and one other, who both required checking every 15 minutes. She said that as far as she was aware four staff members was the correct staffing for Jasmine House that night.

Ms Dickerson said that she started her shift at 19:00 on 10 September 2023 and attended the handover from the day shift leader. She told the court that she did not recall any concerns raised about Mia, or any other child in Jasmine House. She said although she was not Mia’s allocated carer, she had assisted with elements of her care, such as personal care and hoisting her into bed. She said that she had not observed any change in Mia, that she looked happy and that there was nothing different from her standard baseline in her opinion.

“From visual checks I conducted I noted Mia was sleeping well that night. Mia’s favoured sleep position was with her legs tucked under her, her bottom slightly in the air and her body forward…. [Mia was] in this position during some of my visual checks”.

Ms Dickerson said that there are occasions when she would pop in for an extra check, if she were walking past a bedroom and could hear the young person snoring loudly, moving around, crying or anything else that might cause concern. She did not recall conducting any extra checks on 10 September.  

She told the court that one of her tasks on nights was to check the resuscitation trolley. She said that she completed that check at about 05:30am, noting what needed to be replaced and what was expired on a piece of paper which she handed to the Clinical Site Manager, approximately some time between 06:00 and 06:15am.

Ms Dickerson told the court, in her statement, that she recalled being asked to help with Mia. She said Ms Yapichi wanted to administer Mia’s medication through her GT button, but Mia was lying in her favoured position on her tummy and therefore Ms Yapichi could not access the GT and needed assistance for repositioning Mia.

She said that she recalled looking at the clock when she was asked to help, thinking it was already about to be 06:30 and she hadn’t written her notes yet. She told the court that she realised that as soon as she finished helping, she would need to write her notes and complete her other remaining tasks. She said that she remembered telling Laura that she would assist but that she needed to go into another bedroom first.

Ms Dickerson said that she was informed a call was made at 06:35 according to telephone records. She said she could not remember the exact time that she entered Mia’s room. She said Laura went to the side of the bed closest to the medication cupboard and she walked to the other side.

“We both unzipped Mia’s bed at the same time. From what I recall Mia’s head was turned on her right cheek, facing the window”.

Ms Dickerson said that she placed her hand on Mia’s lower back to let Mia know they were there and would be repositioning her. She said I think I said aloud “sorry lovely Mia, we need to turn you over”. She said the reason for saying this was because she was warm and cosy in her preferred sleeping position.

She told the court that she placed her hand on Mia’s scapula and simultaneously felt for breathing. She said that she realised something was wrong and she shouted out Mia was unresponsive. She said that as she shouted out, she repositioned Mia to be flat on her back and she pressed the call bell.

She said another staff member arrived at Mia’s bedroom quickly. Ms Dickerson said that she remembered saying out loud why was there no walled oxygen in this room and she was told Mia was assessed as not needing an oxygen flow meter in her room.

The coroner indicated that Ms Dickerson, in her statement, went on to talk about the resuscitation. She summarised that Mia was placed on the floor and she started to help move her bed. Paramedics attended and the further medical team took over resuscitation.

C: That’s dated 3 June 2024. Is there anything, Mr Walsh, Mr Cox or family members need added?

Mr Walsh: No, I don’t think so.

The coroner then called Laura Yapichi to the stand.