Tadworth care home's 'culture of cover up', coroner says
A coroner says a possible "culture of cover up" at a care facility could lead to further deaths after saying neglect contributed to the death of a 12-year-old girl.Raihana Awolaja from Essex died in hospital on 1 June 2023 following a cardiac arrest while unsupervised in her residential care home in Tadworth, Surrey.A coroner has told The Children's Trust (TCT) that if Raihana had been properly observed she would not have died "on the balance of probabilities".Mike Thiedke, the charity's chief executive, said TCT had completed a thorough review of its care and that Raihana's death had a "profound effect on the way we care for, support, and involve the children and families".
'Systemic failures'
In 2022, Raihana was placed at Tadworth Court, a residential care facility operated by TCT, and required constant one-to-one supervision, the family's solicitors Leigh Day said.In a prevention of future deaths report to the TCT, the senior coroner for inner west London, Professor Fiona Wilcox, said she had concerns "that there may be culture of cover up at the TCT" as they were avoiding "highlighting systemic failures and learning" which could prevent future deaths.The coroner said she also had concerns that TCT did not sufficiently communicate with the local authority or families in relation to issues with care and supervision, and that there were also possible staff training issues.Ms Wilcox said families were not being listened to when they raised concerns.
On 29 May 2023 Raihana had been left unsupervised for about 15 minutes and her breathing tube became blocked.The 12-year-old later died of a hypoxic brain injury in hospital and the coroner gave a conclusion of death by natural causes contributed to by neglect.Ms Wilcox said Raihana's allocated carer left the unit to do an administrative task and handed her care to a nurse due to go off shift.About five minutes later her care was again handed over to a another nurse who did not supervise the 12-year-old as she was caring for another child.
'Gross failure'
Raihana's allocated nurse returned to find she had gone into cardiac arrest and the alarm was raised.Ms Wilcox said: "This failure to adequately observe her was a gross failure in care by the nursing staff."Following Raihana's death, TCT undertook an investigation which failed to uncover what had happened or to understand the cause of her death, the coroner added.Raihana's mother Latifat Kehinde Solomon had also raised concerns to TCT several times after seeing her daughter left unsupervised, the coroner said.
Mr Thiedke said the charity, which "unreservedly" apologised for its "failings", had made improvements to its staff training and put a new system in place to make sure families were heard."In partnership with our regulators and the wider health care system, we have changed how we monitor and observe children and young people and increased frontline staffing levels," he added.TCT says it is considering the report and is planning to submit a response outlining the work that had already being taken, and what was going to change in the future.In March 2024 the trust was warned about inconsistent visual checks during overnight observations at the care facility in Tadworth and seven months later similar concerns were flagged again.
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