One care home, three children's deaths and countless missed warnings
Three disabled children died in similar circumstances at the UK's largest brain rehabilitation centre for children despite warnings about care failings, The Independent can reveal.
Five-year-old Connor Wellsted died in 2017 at The Children's Trust's (TCT) Tadworth unit Surrey, having suffocated when a cot bumper became lodged under his chin.
Six years later, in 2023, Raihana Oluwadamilola Awolaja, 12, died when her breathing tube became blocked and Mia Gauci-Lamport, 16, died after she was found unresponsive in her bed.
Inquests into all three deaths uncovered a litany of failings and identified common problems in the children's care at the home where multiple senior directors earn six-figure salaries.
Now, police have launched a fresh investigation into Connor's death.
Coroners who investigated their deaths criticised staff for failing to adequately monitor the children - all of whom had complex disabilities and needed one-to-one care - and for not sharing the full circumstances of how they died with authorities.
The families of the children, who were all under the care of their local council, are demanding that the government and the regulator, the Care Quality Commission (CQC), take action.
Connor's father Chris Wellsted told The Independent: 'How many more children are going to die because of their incompetence? CQC failed the NHS England failed. The government failed. Every organisation, what should have been investigating the children's trust. It's a disgrace.'
Surrey Police first investigated Conor's death in 2017 but no further action was taken. The force has now admitted that it failed to deploy a detective inspector to the scene, which is protocol following the sudden death of a child - something it admitted 'was a failing on our part'.
It said it would review the investigation to decide if further inquiries into his death are needed. It is not reinvestigating Raihana and Mia's deaths.
'A disgrace'
Connor, from Sheffield, who had neuro-disabilities as a result of a brain injury following a heart attack after birth, was found dead in his cot at TCT on 17 May 2017 after he became trapped under a cot bumper.
Following an inquest into his death, Coroner Karen Henderson ruled TCT had 'misled' authorities over the circumstances of Connor's death, initially telling the police, coroner and pathologist that the cot bumper was found on Connor's chest. Staff also failed to preserve the scene and did not tell police that he had already been dead for hours when staff found him unresponsive in the morning.
The staff also failed to declare that Connor's death was sudden and unexpected, which meant police did not send a detective inspector to the scene, as is typically the case.
In December 2024, the Parliamentary Health Service Ombudsman criticised the CQC for failing to take enforcement action against TCT over his death after it concluded it wasn't necessary.
Connor's father complained about the police's handling of the investigation, which has now prompted the force to reinvestigate.
A letter, seen by The Independent, confirming the fresh probe reads: 'I can confirm that Surrey Police are relaunching a crime investigation into the circumstances of Connor's death in order to establish whether any criminal offences have been committed.'
A key concern over Connor's death, which was also brought up in probes into Raihana and Mia's deaths, was that he had no direct supervision overnight, other than staff opening the door or watching him through a glass window.
'Culture of cover-up'
Raihana, who was from Essex, had complex disabilities as a result of a premature birth and needed around-the-clock care, died at TCT on 1 June 2023.
She had been left unattended for 15 minutes, during which time her tracheostomy tube was blocked. Ms Wilcox said that if she had been 'appropriately observed' this would have been recognised and resolved and, 'on the balance of probabilities, she would not have died at this time'.
She said: 'This failure to adequately observe her was a gross failure in care by the nursing staff. This was compounded by the lack of sufficient staff on the unit where Raihana lived to provide proper 1:1 care.'
Raihana's mother, Latifat Kehinde Solomon, had previously raised concerns about her daughter's care after finding that she had been left unsupervised.
Making a ruling that Raihana died as a result of natural causes contributed to by neglect, Ms Wilcox warned: 'There may be a culture of cover-up at Tadworth Children's Trust.'
She added that the trust had carried out a flawed investigation into Raihana's death, had blamed an 'innocent individual', and as a result, had avoided highlighting systemic failures in the running of the home.
'Warnings not heeded'
Mia Gauci-Lamport, from Bracknell Forest, had Ohtahara syndrome, a severe epilepsy syndrome, and required 24-hour care at TCT.
She had been at the home since 2020, but in September 2023, she was found dead in her bed. She should have had in-person checks every 15 minutes, but staff only used a video camera to check on her.
An external investigation, by consultancy firm Bluebox Associates, seen by The Independent, found TCT did not carry out its obligations under law to inform Mia's family of the circumstances of her death.
During her inquest, the local authority lead for Mia's care said the council was concerned over 'discrepancies' in the reports from TCT concerning when Mia was found and when the ambulance was called.
Mia's sister Paige Gauci Lamport, 24, told The Independent that details of her care only came to light during her inquest. They included concerns that Mia was under the care of a private doctor, paid for by TCT, who was also employed by Great Ormond Street Hospital, when she should have been assigned a specialist NHS team.
Concluding Mia's inquest, Coroner Karen Henderson, who also investigated Connor's death, raised concerns that her previous warnings about TCT's failings appeared to have been ignored.
She said: 'The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD [Prevention of Future Deaths] report I issued following the inquest touching on the death of Connor Wellsted at TCT in 2022.'
Mia's sister has called for action from the government to prevent further deaths: 'When will this end? When is it they're going to finally take some action?'
'I just think one child, accident, two a coincidence, three is a pattern. I think more action needs to be done. I think people with disabilities don't have a voice, really.'
'I just think they [The Department for Health and Social Care and CQC] have a duty to make sure that these kids are being looked after… I just think because they are disabled kids and they don't have a voice, it's just easy to pass it on.'
In response to the deaths, Mike Thiedke, chief executive of TCT, said the trust was 'determined to learn and improve, not to hide or minimise if something has gone wrong'.
He said that where the trust has not met its own high standards, it had acknowledged and apologised. He added the trusts had since adopted a new patient safety approach that involves families.
Commenting on the fresh police probe into Connor's death, he added: 'The Children's Trust continues to send our most heartfelt condolences to Connor Wellsted's family. We understand that Surrey Police are conducting a review of how Connor's death has been handled, including by the police. We will make ourselves available to the police and cooperate fully.'
Lucy Harte, deputy director of multiagency operations at CQC said: 'Our sincere condolences go to the families of Connor, Mia and Raihana. The impact of such a loss is deep and profound. The importance of understanding what happened and what can be done to keep people safe in the future can't be overstated.'
She said the CQC had provided detailed responses to coroner's concerns for Mia and Connor and was reviewing its response to Raihana's inquest.
The Department for Health and Social Care would not comment directly on what action should be taken concerning TCT but said it would expect the CQC to use its powers where providers are failing to give adequate care to patients.
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