Latest news with #healthcarefailures
ABC News
17-07-2025
- Health
- ABC News
Coroner finds 'lost opportunities' prior to death of eight-month old infant
Queensland's deputy coroner has found a series of "lost opportunities" surrounding the death of an eight-month-old boy at his north Queensland home. Daniel Thomas Wright was born in the Townsville University Hospital at 24 weeks' gestation in July 2018 and remained there until he was discharged to the Mackay Base Hospital (MBH) on February 6, 2019. The following two months included some time at home along with multiple presentations to the Mackay and Bowen hospitals. He died on March 30, 2019 — 11 days after being discharged from MBH for a second time. Deputy Coroner Stephanie Gallagher has this week handed down her findings after hearings in 2024 examined whether it was appropriate to send Daniel home into the care of his parents, who were reported in the findings as having intellectual impairments. The inquest also examined the sharing of information between the Townsville and Mackay hospitals, health services and the Department of Child Safety. The inquest heard that an autopsy found the baby died due to prematurity-associated lung and bowel disease and had a series of hospital admissions for weight loss. Hospital workers in Townsville and Mackay gave evidence about the difficulties Daniel's parents, Zara Williams and Benjamin Wright, had in understanding his needs and their ability to comply with his feeding. A social worker at the Townsville University Hospital, where the baby stayed for his first seven months, told the inquest she had concerns about Daniel's parents' capacity to care for themselves and raise him. She said she did not contact the Department of Child Safety because the baby was not ready for discharge at that time. Daniel was first brought to the department's attention in February 2019, after he was moved from Townsville to MBH. Two days after he was discharged in Mackay, Daniel was taken to Bowen Hospital and transferred the following day back to MBH. His case was then referred to the Suspected Child Abuse and Neglect (SCAN) team, but Daniel's recovery saw him discharged from MBH for a second time on March 19, the inquest heard. He died on March 30. In her findings, Ms Gallagher described the decision to discharge Daniel from Townsville to Mackay on February 6, 2019, to be closer to the family's home in Bowen, as "appropriate". She said the decision to discharge the baby from MBH the first time was "finely balanced" and while medically sound, "perhaps placed an over-reliance on Daniel's parents' ability to care for him". However, Ms Gallagher said that the decision to discharge the baby for a second time from MBH was not appropriate, based on his "ongoing failure to gain weight". The deputy coroner said it was possible that alerting child safety earlier would have allowed time for an assessment of his parents' capacity to care for him and to engage in an intervention program to support his care. Ms Gallagher said Daniel's parents' ability to care for him should have been considered more carefully by his treating practitioners and by child safety. The deputy coroner noted medical records which showed both parents struggled to understand their responsibilities, and "needed constant prompting and correction". The records also observed Mr Wright was "often aggressive, abusive, resistant to medical advice and dismissive of Daniel's needs". She noted that child safety had determined an Intervention with Parental Agreement (IPA) as the most appropriate care plan, based on its judgement that the parents were willing to work with the department and keep the child's home safe. The Mackay Hospital and Health Service (MHHS) submitted that doctors needed to "work within" the IPA unless Daniel's condition deteriorated so that his death was imminent. In her findings, the deputy coroner said there was no single failing that would have changed the outcome for Daniel. "Rather, there were a series of lost opportunities to share information about his case between the QH [Queensland Health] and Child Safety, combined with what was perhaps a global under-appreciation of Daniel's vulnerability and fragility," she said. In submissions, the Townsville and Mackay Hospital and Health Services (MHHS) argued if there was no medical reason to keep the infant as an inpatient, and his parents wished to discharge him, there was no option to "compel a stay in hospital". While the coroner described MHHS' home support for Daniel's parents as extensive, it was ultimately "inadequate". Ms Gallagher also criticised child safety's response and said risk assessments did not adequately consider the risk of future harm to Daniel. The inquest heard the hospital and health services, and child safety had since made changes in regard to information sharing across all government agencies. "There are no practical recommendations which I could now make to prevent similar deaths in the future," she said.
BBC News
15-07-2025
- Health
- BBC News
Couple feel vindicated by critical report into maternity care
A mother who played a key part in pushing for change in a health board's maternity care said she felt vindicated following the publication of a report highlighting Channon's son Gethin was disabled due to failings made during his birth in 2019."It's been a long journey for us, battling to get acknowledgement for what has been going on at Swansea. All the way up to Welsh government level we have been fighting."An assessment of all maternity services in Wales will now have an independent chair following the head of the Birth Trauma Association said it needed to take a thorough look at the culture of maternity units. Mrs Channon said she and her husband Rob "have frequently been brushed off" and ignored, however they now feel the health board has added that an unreserved apology "goes a long way to mend bridges with families who have felt adrift".Rob Channon added: "We do have faith that the new leadership want to make change, we just have to give them time. "If they don't make changes, we will have to hold them accountable for that."Maternity services across the UK have come under the spotlight, with the health secretary in England announcing "a rapid national investigation" into NHS maternity and neonatal services, following a series of maternity scandals going back more than a who support families that have experienced birth trauma argue the same mistakes were being made, with little sign that lessons were being learned. Julia Reynolds heads up legal firm Leigh Day in Wales, and as a medical negligence specialist said the issues had not changed in years."I see cases from all of the health boards across Wales and the issues we see are similar," she said."I have significant concerns about the quality of maternity care across Wales."The review of care in Swansea found that debriefs with families and responses to complaints lacked Reynolds said after losing a baby many families struggle to deal with being told "it was one of those things"."While staff might feel they're doing the right thing by potentially offering reassurance to families, what that really does is just leave those parents without answers, and really nagging doubts.""I do believe it's a disservice to families and I think it's really important for families to have answers, to understand what went wrong and even more importantly, for those children to get that early treatment to get the better outcome." The independent review into care at Swansea Bay included testimony from women who felt vulnerable, brushed off when they raised concerns, and as a result felt guilty for not speaking up for themselves women spoke of a lack of compassion, others felt belittled, and birthing partners felt powerless or called for improvements to the complaints process in Wales to make it less rigid and more Bay health board apologised unreservedly "to all women and families whose care has fallen well below the expected standard" and was working on an improvement Welsh government also apologised, and accepted all recommendations in full. Director of the Royal College of Midwives in Wales, Julie Richards, said the written policies, frameworks and statements from the Welsh government set out positive intentions."However, they cannot be achieved without investment and proper workforce planning."Over the past number of years reports and reviews into maternity services in Wales are sadly flagging the same key issues that are impacting the delivery of safe care, understaffing, underfunding, working culture and not enough emphasis or time for crucial multi-disciplinary training."Our members are seeing a rise in more complex pregnancies, with women requiring more specialist support during pregnancy so it's never been more important to get this right." A big theme from the report into care given in Swansea Bay was that women were not listened to."It's very easy sometimes for staff to dismiss a woman who's distressed as being over-dramatic," said Kim Thomas, from the Birth Trauma Association."We hear quite a lot that women are told they're making too much of a fuss. But when they try to remain calm there's an assumption there's probably nothing wrong."It creates real problems for women. This is where listening comes in - if a woman says she thinks something's wrong, then actually listen to her."The issues were all the more pressing given the disparities experienced by black women across the mortality is almost four times higher than that of white women, with significant disparities for Asian and mixed ethnicity women too. Umyima Sunday said she experienced good care when she delivered her second child at Singleton hospital two years ago, but her labour progressed so quickly she delivered her daughter on the ward."Even in pain, I'm really calm," said the 33-year-old, who moved to Swansea from Nigeria to study a post-graduate course in public health three years ago."I would say they were looking at me thinking, 'she's not in so much pain'."But a woman that has gone through that before knows how her body reacts. They didn't really understand that I was really in pain and needed them at that time."She said that while staff were listening, they lacked urgency, meaning no one was there to guide her through contractions and when to push."I just wanted the baby out and couldn't think properly - if I had someone beside me, guiding me through the process, I would have avoided the tears I had during the process." Perpetua Ugwu, 34, also considered her labour to be "smooth and straight forward" for her second child, and "nurses and midwives attended to me very well".Though she was initially told over the phone to "exercise a little bit of patience" when she told staff labour had started."If I had waited a little longer I would have given birth at home. If I hadn't taken that step to go into the hospital I would have delivered at home, because they didn't believe that my labour was there."But I knew what I was feeling and I knew that my labour is not long, it's usually short."Her waters broke in the taxi to hospital and her baby was born around 30 minutes said if she could change one thing it would be to "take away that stereotype of black women being able to tolerate pain more."We all go through labour in different ways, but if someone complains she is feeling pain or not feeling well, the best they can do is give the person attention. Don't let them wait a little longer."
BBC News
15-07-2025
- Health
- BBC News
Lampard mental health inquiry hears of 'lack of humanity'
The counsel to an inquiry looking into deaths in mental health inpatient units said evidence from bereaved relatives reflected "a lack of empathy and humanity" in mental Lampard Inquiry is the first to investigate the deaths of more than 2000 people on mental health wards between 2000 and the end of a statement that closed the latest round of hearings, Nicholas Griffin KC described how one patient, Geoff Toms, 88, was placed in nappies, even though he could use the toilet, and how some hospitals felt more like of the main trusts responsible for mental healthcare, the Essex Partnership University NHS Foundation Trust (EPUT) has apologised to those failed. Mr Griffin paid tribute to relatives who had shared their personal experiences saying they had acted with "confidence, courage and expressions of love".Lynda Costerd, the daughter of Geoff Toms, was one of those giving evidence. She described her father's experience on Beech Ward at Rochford Hospital, an older person's mental health died in May 2015 and she says he was on the ward for less than 6 days, when he suffered injuries. "He was basically put in a chair, and they would take his walker away from him, so that he couldn't get up and move, so much so, they put him in nappies... even though he wasn't incontinent," she Costerd believed he was becoming malnourished, and said he was so thin that "you could see his pacemaker".She explained how Mr Toms had broken his nose during falls on the ward. She also said he had two black eyes and bruising to his face and looked like "he had been mugged".Ms Costerd said her mother told medical staff Mr Toms needed to see a she said they replied: "It doesn't work like that. You can't just say you want a doctor." 'Dire circumstances' The inquiry also heard how Pippa Whiteward, the mother of a baby, was restrained and handcuffed to a bed by police when - while in crisis - she attended the accident and emergency department at Broomfield Hospital in sister Lydia Fraser-Ward described how Ms Whiteward's husband had called it an "NHS version of a prison cell".She said her sister had been transported to Staffordshire as it was the only mother and baby unit bed available in the whole told the inquiry: "If there are really that few beds in this country for mothers with young babies who are having a mental health crisis that they have to ferry them around in ambulances, hundreds and hundreds of miles, just to give them a bed, then we are in really dire circumstances, aren't we?"Ms Whiteward, aged 36, took her life in October 2016 after being discharged. Another relative who gave evidence was Emma Cracknell, who spoke about her mother Susan Spring, who patrolled the streets of London as a Met police described how Ms Spring had not suffered from mental health problems in the past and how, when she tried to take her life, she was not assessed by a psychiatrist or sectioned to a mental health inpatient bed. After giving evidence, Ms Cracknell told the BBC: "I know she would have wanted to have her voice heard. I know the care she was given was not adequate."When you lean on a service like the crisis team, you just pin all your hopes on the fact they know what they're doing," she she added they knew they were not alone, and she hoped the inquiry could "bring around change". Mr Griffin said inquiry chair Baroness Lampard's team remained "disappointed" with the number of staff volunteering evidence, adding they were "few in number".It could be 2026 before staff are called to testify. In October relatives will continue to give their Griffin said mental health did not receive the attention it merited, given one in four adults and one in 10 children experience mental illness. "Chair, I know it is your hope that the Lampard Inquiry contributes to a wider conversation, that the public will engage in this, and that the media will reflect these experiences," he chief executive Paul Scott has apologised for deaths under his trust's said: "As the inquiry progresses, there will be many accounts of people who were much loved and missed over the past 24 years and I want to say how sorry I am for their loss."Baroness Lampard is expected to produce a final report in 2027. Follow Essex news on BBC Sounds, Facebook, Instagram and X.
CNN
10-06-2025
- Health
- CNN
Top RFK Jr. aide attacks US health system while running company that promotes wellness alternatives
Calley Means has built a following within the 'Make America Healthy Again' movement by railing against the failings of the U.S. health system, often pinning the blame on one issue: corruption. Means, a top aide to Health Secretary Robert F. Kennedy Jr., was hired as a White House adviser in March. He has used that perch to attack the nation's leading physician groups, federal agencies and government scientists, claiming they only protect their own interests in the nation's $4.9 trillion-a-year industry. In recent interviews, speeches and podcasts he has called the American Medical Association 'a pharma lobbying group,' labeled the Food and Drug Administration 'a sock puppet of industry,' and said federal health scientists have 'overseen a record of utter failure.' Means, however, has his own financial stake in the sprawling health system. He's the co-founder of an online platform, Truemed, that offers dietary supplements, herbal remedies and other wellness products. Some of the vendors featured on Truemed's website are supporters of Kennedy's MAHA movement, which downplays the benefits of prescription drugs, vaccines and other rigorously tested medical products. Kennedy has pledged to run the Department of Health and Human Services with 'radical transparency,' but Means has never had to publicly disclose his own financial details or where exactly they intersect with the policies he's advancing. 'It reeks of hypocrisy,' said Dr. Reshma Ramachandran, a health researcher at Yale University. 'In effect, he is representing another industry that is touting nonregulated products and using his platform within the government to financially benefit himself.' In a written statement, Means said his government work has not dealt with matters affecting Truemed and has focused on issues like reforming nutrition programs and pressuring companies to phase out food dyes. 'Pursuing these large-scale MAHA goals to make America healthy has been the sole focus in my government work,' Means said. Truemed helps users take tax-free money out of their health savings accounts, or HSAs, to spend on things that wouldn't normally qualify as medical expenses, such as exercise equipment, meal delivery services and homeopathic remedies — mixtures of plants and minerals based on a centuries-old theory of medicine that's not supported by modern science. The business model caught the attention of the IRS last year, which issued an alert: 'Beware of companies misrepresenting nutrition, wellness and general health expenses as medical care.' Truemed co-founder and CEO, Justin Mares, said in a statement the company is 'in full alignment' with IRS guidelines. 'Truemed enables patients to work with providers to use medical funds for root cause interventions like exercise and vitamin D to reverse disease under current law,' Mares said. The full extent of Means' potential conflicts — including his personal investments— are unclear because of his status as a special government employee. Unlike presidential appointees and other senior officials, special government employees are temporary staffers who do not have to leave companies or sell investments that could be impacted by their work. Also, their financial disclosure forms are shielded from public release. 'It's a big problem,' says Richard Painter, a former White House ethics lawyer under George W. Bush now at the University of Minnesota. Painter and other experts have raised alarms over a whirlwind of Trump administration actions to dismantle the government's public integrity guardrails. Still, part-time government employees are subject to the same law that bars all federal staffers from working on issues that could directly benefit their finances. When such cases arise, they must recuse themselves or risk criminal penalties. Means regularly opines on matters before HHS, including rethinking the use of drugs for depression, weight loss, diabetes and other conditions. Recently he's been promoting a new government report that calls for scaling back prescription medications in favor of exercise, dietary changes and other alternatives. 'If we rely less on our medical system, less on drugs, it necessitates the spiritual, cultural conversation about what we're doing to our children's bodies,' Means said in a recent podcast appearance. Experts note that government ethics rules are intended to both prevent financial conflict violations, but also the appearance of such conflicts that might undermine public trust in government. 'If I were running the ethics office over at HHS, I sure as heck wouldn't want anybody going around giving interviews and speeches about government matters that could have an effect on their own financial interests,' Painter said. Means' rapid rise reflects the seeming contradictions within the MAHA movement itself, which urges followers to distrust both big corporations and the government agencies which regulate them. Means rails against big pharma and food conglomerates, two industries that he says he spent years working for as a consultant in Washington. Means has no medical training. A graduate of Harvard Business School, he previously ran a bridal gown startup with his wife. On Wednesday, he's scheduled to be the keynote speaker at FDA's annual science forum, according to a copy of the program shared with The Associated Press. He traces his passion for health care reform to the death of his mother from pancreatic cancer in 2021. Shortly thereafter, Means and his sister, Dr. Casey Means, took psychedelics together and had 'a mind-blowing, life-changing experience,' which led them to co-author a wellness book, launch separate health startups and begin appearing on podcasts. Casey Means was recently nominated to be surgeon general and has faced scrutiny over her qualifications, including an unfinished medical residency. Asked about her nomination, President Donald Trump said: 'Bobby thought she was fantastic,' adding that he did not know her. Meanwhile, her brother has stepped up his rhetoric for the MAHA agenda, recently declaring that Kennedy has 'a spiritual mandate to reform our broken system.' While promoting the administration's accomplishments, Means does not shy away from plugging his own brand or those of his business partners. When asked to offer health advice to listeners of a sports podcast, Outkick The Show, in April, Means said: 'Read our book, 'Good Energy.'' He also recommended blood tests sold by Function Health, which provides subscription-based testing for $500 annually. The company was cofounded by Dr. Mark Hyman, a friend of Kennedy and an investor in Truemed, which also offers Hyman's supplements through its platform. Casey Means is also an investor in Hyman's company. 'If you're sick, most likely you have some kind of nutrient deficiency, some kind of biomarker that you can actually then target with your diet and your supplements,' Calley Means said. Like dietary supplements, the marketing claims on laboratory tests sold by Hyman are not approved by the FDA. The agency has warned for years about the accuracy of such tests and tried to start regulating them under President Joe Biden. Experts say MAHA entrepreneurs like Hyman are following a playbook common to the wellness industry: Identify a health concern, market a test to diagnose it and then sell supplements or other remedies to treat it. 'It ends up favoring these products and services that rest on flimsy grounds, at the expense of products that have actually survived a rigorous FDA approval process,' said Dr. Peter Lurie, a former FDA official who is now president of the Center for Science in the Public Interest. Many of the items sold via Truemed, including sweat tents, cold plunge tanks and light therapy lamps, wouldn't typically qualify as medical expenses under rules for HSAs, tax-free accounts created by Congress to manage medical costs. The IRS generally states that HSA purchases must help diagnose, cure, treat, mitigate or prevent disease. Truemed allows users to request a 'letter of medical necessity' from a doctor, stating that the product in question could have medical value for them. Like other telehealth services, there's usually no real-time communication with the patient. The physician reviews a 'simple survey solution,' filled out by the Truemed user, according to the company's website. Industry representatives say customers should be careful. 'You need to be prepared to defend your spending habits under audit,' said Kevin McKechnie, head of the American Bankers Association's HSA council. 'Companies are popping up suggesting they can help you manage that process and maybe they can — so the debate continues.' Americans have an estimated $147 billion in HSA accounts, a potential windfall for companies like Truemed that collects fees for transactions made using their platforms. Means sees an even bigger opportunity — routing federal funds out of government programs and into more HSAs. 'The point of our company is to steer medical dollars into flexible spending,' Means told fitness celebrity Jillian Michaels, on her podcast last year. 'I want to get that $4.5 trillion of Medicare, Medicaid, everything into a flexible account.' Means' pitch for expanding HSAs echoes two decades of Republican talking points on the accounts, which were created in 2003 to encourage Americans in high-deductible plans to be judicious with their health dollars. But HSAs have not brought down spending, economists say. They are disproportionately used by the wealthiest Americans, who have more income to fund them and a bigger incentive to lower their tax rate. Americans who earn more than $1 million annually are the group most likely to make regular HSA contributions, according to an analysis by the nonprofit Center on Budget and Policy Priorities. More than half Americans with HSAs have balances less than $500. Trump's 'One Big Beautiful Bill' would further expand HSA purchases, making gym memberships and other fitness expenses eligible for tax-free spending. That provision alone is expected to cost the government $10 billion in revenue. 'These are really just tax breaks in the guise of health policy that overwhelmingly benefit people with high incomes,' said Gideon Lukens, a former White House budget official during the Obama and Trump administrations, now with the Center on Budget and Policy Priorities. Expanding HSA eligibility was listed as a goal for a coalition of MAHA entrepreneurs and Truemed partners, founded by Means, which lobbied Congress last year, according to the group's website. Means said in a statement that the group focused only on broad topics like 'health care incentives and patient choice — but did not lobby for specific bills.' In total, the HSA expansions in Trump's bill are projected to cost the federal government $180 billion over the next 10 years. As HSAs expand to include more disparate products and services, Lukens says the U.S. government will have fewer dollars to expand medical coverage through programs like Medicaid. 'We have a limited amount of federal resources and the question is whether we want to spend that on health and wellness products that may or may not be helpful for wealthy people,' Lukens said.
The Independent
10-06-2025
- Health
- The Independent
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.
