In July and August I was in court in Woking to report on the inquest following the death of Mia Gauci-Lamport. Mia died in September 2023, aged just 16, at The Children’s Trust in Tadworth. You can read all my inquest reporting here.
Last week the coroner, Dr Karen Henderson, issued a Prevention of Future Death Report.
Some of you might remember my reporting, two years ago, around the death of Connor Wellsted. Connor was 5 when he died, at The Children’s Trust in Tadworth, in May 2017. His inquest was not heard until five years after his death.
After Connor’s inquest, heard by the same coroner, she issued a Prevention of Future Death Report.
At the time of Connor’s inquest the coroner’s ongoing concerns related to:
- the cot used by Connor
- monitoring of Connor during the night
- probity and investigation by The Children’s Trust, Tadworth
- senior management at The Children’s Trust.
Two years later, at Mia’s inquest the coroner’s ongoing concerns related to:
- lack of appropriate monitoring of Mia during the night
- medical care provided to Mia
- senior management at The Children’s Trust.
Overnight monitoring at The Children’s Trust, Tadworth
So how is it that two children have died in recent years, at the same place, overnight, and staff have been found to not completing nighttime monitoring appropriately?
In Connor’s PFD issued in May 2022, the coroner said this:
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.
In their response to Connor’s PFD Report, dated 8 July 2022, The Children’s Trust had this to say about overnight monitoring:
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.
The Children’s Trust also claimed to have benchmarked their sleep monitoring policy against that of other similar organisations, finding it to be “more robust, both in terms of the frequency and nature of checks undertaken”.
They added in their response that their own internal audits of the sleep monitoring policy (which appeared to rely on an audit of records and paperwork, not observation of actual practice) found a high level of compliance “The most recent audits in September 2021 and January 2022, respectively reported 99.4% and 98.1% compliance, respectively”.
So how is it that Mia died two years later, and the coroner’s concerns remain? This is what she had to say at the conclusion of Mia’s inquest:
Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified. Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation.
Senior management at The Children’s Trust, Tadworth
After Connor’s inquest in 2022, the coroner had concerns that the lack of transparency, openness and candour by the Senior Management Team at The Children’s Trust, gave rise to a concern about a lack of insight, the consequence of which was a failure to learn from adverse events:
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.
Two months later in their response The Children’s Trust had this to say:
We are, of course, saddened by the coroner’s finding that we were said to have lacked transparency and openness around Connor’s death. However, we are also an organisation that is committed to listening and responding to all feedback, even when it is difficult to hear.
We accept the coroner’s finding that we did not properly investigate the circumstances of Connor’s death and that we could have highlighted the potential role of the cot bumper more explicitly to the pathologist via the Coroner’s Office. However, these oversights were as a result of a lack of experience in responding to and investigating an unexpected child death, rather than from any intention to mislead.
The coroner heard evidence from the former director of clinical services, the former medical director and the current medical director. The evidence of our current medical director intended to provide the court with further information in respect of the changes implemented following our internal investigations and wider learning across The Children’s Trust.
Both our current medical director and the former director clinical services offered their unreserved apologies to the family in respect of Connor’s tragic death and the conduct of our subsequent investigations.
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.
We want to reassure Connor’s family, and others, that we will do everything we can to ensure that something like this cannot happen again.
It seems that despite their stated intentions, The Children’s Trust have failed to deliver on their promises. Something like this has happened again. This is what the coroner said in the latest PFD, following Mia’s inquest conclusion:
3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
Medical care provided to Mia
In addition to the issues that remain concerns after two years, at Mia’s inquest another concern was identified, relating to how The Children’s Trust provided medical care to children for whom they are responsible.
The evidence at inquest was somewhat opaque to say the least. The coroner identified concerns that Mia’s medical records at The Children’s Trust were “neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented”.
Mia had a number of health needs and the investigator employed by The Children’s Trust found that PEWS score assessments “were not undertaken to ensure Mia’s well-being despite it being within her care plan”.
There was also no documented evidence that an MDT clinical review was regularly undertaken, or indeed was ever undertaken “to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs”.
The coroner found that The Children’s Trust practice of privately contracting consultants, without terms of reference, and sporadically as funding would allow, left Mia outwith the NHS specialist consultant led care to which she was entitled. Mia’s family told me at the time of her inquest that they had been told she was under the care of Great Ormond Street consultants, but it appears this was not the case. The coroner said this:
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro- consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life- limiting condition.
The Children’s Trust have yet to respond to the latest PFD, but when I contacted them for a statement at the conclusion of Mia’s inquest, they said they would reply in a timely manner, adding:
Once received, we will be carefully considering the recommendations made by the coroner, together with our own independent investigations conducted since Mia’s sad death. We are determined to understand any lessons we can draw from Mia’s sad death. We are working together with all relevant authorities to enhance our delivery of high quality, safe and effective care and learning for the children in our care.
It will be interesting to see what The Children’s Trust say in response this time. I’ll finish with some of the words of Mia’s family, from their statement given to me when Mia’s inquest concluded:
Mia was the most beautiful little girl and left an imprint on everyone she met. We are overall happy with the result from Mia’s inquest and as a family we are very relieved that a Prevention of Future Deaths Report has been submitted against The Children’s Trust for a second time as they did not learn from the first Prevention of Future Deaths against the lovely Connor.
We are devastated as a family to know that two children have now died at the Trust and they as a charity have failed them both for various of reasons, due to their night protocols not being followed as well as the care plans and failures from the management.
It’s disappointing as a family that The Children’s Trust’s Duty of Candour towards us was very limited, having to wait until an outside body flagged that their communication and support towards us as a family was poor. As well as receiving no formal apology from The Children’s Trust since Mia’s passing.
However, we would like to thank the staff who done Mia’s every day care and schooling at the Children’s Trust because Mia thrived due to this. A massive thank you for all the hard work and love that Bracknell Forest Social Care have given Mia, and us as a family, over the numerous years, it’s been outstanding to say the least.