Nurses to face regulator over a case involving the death of a 5-year-old after failings by a flagship UK care home

Independent

19-06-2025

Four nurses who cared for a 5-year-old who died at a children's care home are being by the UK's nursing watchdog after The Independent revealed xx
The Nursing and Midwifery Council initailly found there was no case to answer over Connor Wellsted's death but reopened the investigation a year later.
Connor died while being treated at The Children's Trust, the UK's largest rehabilitation unit for children with brain injury, in 2017. His death came after a litany of failings xxxx
The NMC, which regulates nurses and midwives in the UK, has decided to take forward fitness to practice probes into four registrants.
The nurses were referred in June 2022 and the NMC initially closed investigations. After a review of its decision, the regulator decided all cases should be reopened.
Last week, The Independent revealed Surrey police have reopened a probe into the handling of Connor's death.
The UK's nursing regulator has opened investigations into four clinicians over a case involving the death of a 5-year-old after failings by the UK's largest rehabilitation unit for children with brain injury, The Independent can reveal.
The Nursing and Midwifery Council, which regulates nurses and midwives in the UK, has decided to take forward fitness to practice probes into four registrants, over the case of Conner Wellsted, a 5-year-old who died at The Children's Trust in 2017, following a litany of failures.
This comes after the regulator initially closed investigations after the nurses were referred in June 2022. After a review of its decision, the regulator decided all cases should be reopened.
The regulator has now decided that all four nurses should face a fitness to practice committee hearing.
The Children's Trust is the UK's largest brain injury rehabilitation unit for children and is used by the NHS and local authorities across the country.
Last week, The Independent revealed Surrey police have reopened a probe into the handling of Conner's death.
Now, the UK's nursing regulator has confirmed that it received referrals against four registrants in relation to Conner's case in May 2022 and that in June 2025, following an investigation, it decided the nurses have a case to answer and will each face a fitness to practice committee.
No interim conditions were placed on the nurses' licences to practice.
Conner Wellsted was the first of three disabled children to have died whilst in the care of The Children's Trust. His death came six years before Raihana Oluwadamilola Awolaja and Mia Gauci-Lamport, in June and September 2023, respectively.
Multiple failings have been identified in all three children's deaths, including a failure to appropriately monitor the children.
In 2022, Coroner Karen Henderson found Conner died after a cot bumper, which was not properly secured, came loose and obstructed his airway.
The inquest found TCT 'failed to keep Conner safe in his cot.'
Among concerns highlighted by the inquest was the fact that Conner had 'no regular or direct supervision during the night.'
The inquest also revealed that staff did not fully inform the police and coroner's services as to the circumstances of his death.
Police were not told of the position Conner was found in and that he had been dead for some time, or that the padded cot bumper was initially found across his neck.
According to the outcome of a complaint to the police in summing up the coroner said: 'I do not accept the evidence that when Connor was found deceased, the bumper was lying on Connor's chest or that it was not impeding him in any way...I am also satisfied given the rigidity and the firmness of the bumper that some force was needed to remove the bumper although it remains unclear who removed the bumper and whether that involved one or two members of the nursing staff lending considerable support to indicate that Connor was entrapped.
'Thereafter, I am also satisfied that the bumper was removed from Connor's neck and then at some point it was likely to have been placed back on Connor's chest which was thereafter found by other nursing staff who were asked to attend Connor as an emergency.'
The prevention of future deaths report also states TCT's chief nurse and medical director were concerned about the role the bumper played in his death; however, they did not keep a copy of his medical records or inform the relevant statutory bodies and arguably 'misled' the CQC.
The pathologist was also not informed of the circumstances of his death, which prevented a post-mortem from taking place to establish whether the cot bumper played a part in his death.
'An Innocent individual'
Last month, Coroner Fiona Wilcox issued a prevention of future deaths report following the death of Raihana in June 2023. The report found there was a 'gross failure in care by nursing staff' after they failed to adequately observe her.
However, the inquest also revealed that following Raihana's death, TCT undertook an investigation which failed to uncover the cause of death. This resulted in a nurse to whom Raihana's care had been handed being 'blamed by the TCT and was referred to the Nursing and Midwifery Council erroneously.'
The inquest also found 'issues with the credibility of another nurse (nurse two) who should have been caring for Raihana.'
Coroner Wilcox warned: 'There may be a culture of cover-up at the TCT, in that they carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths.'
In response to the Coroner's allegations about the erroneous referral to the NMC, The Children's Trust said: 'We accept that the initial external investigation was inadequate and did not sufficiently explore systemic factors. We later identified these issues and undertook further work to strengthen our organisational learning. The extensive evidence presented to the coroner during the inquest helped clarify the events that led to Raihana's death and enabled us to improve the way we manage and investigate incidents.'
'Raihana's death has prompted significant reflection, change, and action across our organisation. We are working hard to build a no-blame culture and support our specialist staff to meet our high standards of care. We've made significant changes to how we review and respond to concerns - focusing on learning, not blame.'
It said it has implemented the Patient Safety Incident Response Framework (PSIRF), 'which shifts the emphasis from individual fault to understanding wider systemic issues.'
The Nursing and Midwifery Council were sent a copy of Raihana's prevention of future deaths report.
In a response to The Independent, it said: 'We are aware of the tragic deaths of Connor, Raihana and Mia and our thoughts are with their loved ones.'
'We can confirm that we have received the prevention of future deaths report in relation to Raihana's sad death and are considering the appropriate next steps.'
'We are only able to confirm whether an individual is under investigation in certain circumstances, which is generally if we have completed an investigation and case examiners decide there is a case to answer.'
The NMC confirmed in the case of Conner Wellsted that its case examiners have decided there is a case to answer in relation to four registrants and have recommended they proceed to a fitness to practise committee.