Coroner urges action at Surrey care home to prevent future deaths of vulnerable children

A coroner is calling on The Children’s Trust in Tadworth, Surrey, and other relevant authorities to urgently improve care standards to stop further deaths of children needing one-to-one nursing support.

Following the death of 12-year-old Raihana Oluwadamilola Awolaja, from Essex, in June 2023, Professor Fiona J Wilcox, Senior Coroner for Inner West London, highlighted serious failings in the supervision and care provided at the residential home.

Raihana, who had complex medical needs and depended on a tracheostomy to breathe, died after being left unsupervised for about 15 minutes. During this time, her tracheostomy tube became blocked, causing her to stop breathing. Although resuscitation was attempted, she later died of brain injury caused by lack of oxygen.

Culture of "Cover Up"

The coroner’s report pointed to “gross failure in care” by staff and a shortage of enough nurses to provide the constant one-to-one support that vulnerable children like Raihana require.

It also found poor communication between The Children’s Trust, social services, and the family, as well as inadequate investigations into incidents when children were left unattended.

Professor Wilcox warned of a possible culture of cover-up at the care home, saying that the investigation into Raihana’s death was flawed and wrongly blamed an individual rather than addressing wider system failures.

This approach risks hiding the real problems and losing important lessons that could prevent future tragedies.

It also found poor communication between The Children’s Trust, social services, and the family, as well as inadequate investigations into incidents when children were left unattended.

Professor Wilcox expressed concerns that children needing close supervision are still sometimes left with less care than they require. She warned of a possible culture of avoiding responsibility at the care home and urged that lessons must be learned to prevent further tragedies.

The coroner outlined several areas needing urgent attention, including:

• Ensuring children who require one-to-one care receive proper supervision at all times.
• Improving staff training on care priorities and what one-to-one care involves.
• Enhancing communication between care homes, social workers, and families, particularly about safety concerns and staff conduct.
• Conducting thorough and transparent investigations into incidents, avoiding blame on individuals when systemic problems exist.
• Taking complaints from families seriously and acting on them promptly.

The Children’s Trust has been given 56 days to respond, detailing the actions they plan to take to address these issues and prevent future deaths.

The Chief Executive of The Children’s Trust, said: “Raihana was not being observed to the standard that the organisation would expect in the period immediately before she was found unresponsive on the evening of 29 May 2023.

“Following this heartbreaking experience, we have increased frontline staffing levels and changed how we monitor and observe children and young people in partnership with our regulators and the wider health care system.

“On behalf of The Children’s Trust, we express our most heartfelt condolences to Raihana’s family and acknowledge how difficult the inquest must have been.”

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