The death of an East London girl in local authority care who was left alone by staff at a children’s home was contributed to by neglect, a coroner has found. Raihana Awolaja, 12, died at a South London hospital after falling ill at Tadworth Court care home run by The Children’s Trust in Surrey in June 2023, following a breakdown of 24-hour one-to-one care that she was meant to be receiving.
Born prematurely at 27-weeks in Romford in 2011, but a looked-after child under the care of Croydon Council at the time of her death, Raihana had complex disabilities, including dependence on a tracheostomy tube to breathe. The inquest heard Raihana’s mother, Latifat Kehinde Solomon, had serious concerns about her daughter’s care and had repeatedly found Raihana without one-to-one care during visits. Latifat recalled raising this potentially dangerous situation several times.
On the evening of Monday 29 May 2023, records showed that the nurse responsible for observing Raihana chose not to monitor her oxygen levels and instead, left and went to another building to complete some admin work. A nurse who was asked to cover had ended her shift, so she asked another colleague, but Raihana was left on her own.
Records show that when the nurse returned from her admin task, she found Raihana in cardiac arrest and that CPR was performed and an ambulance called. Raihana had been left alone for a total of 15 minutes. She died in St George’s Hospital in Tooting three days later.
In her conclusion, the coroner said that there appeared to be confusion between Croydon Council and The Children’s Trust as to the meaning of one-to-one care. The inquest also heard that Tadworth Court had insufficient staff available to consistently cover patients one-to-one, and that individual staff members were regularly left caring for at least two patients at a time.
The coroner criticised the nursing staff involved, according to Leigh Day Solicitors, as she found that it was likely that had Raihana been properly observed, the deterioration in her condition would have been identified and her life saved.
‘Culture of cover up’
Now the coroner Professor Fiona Wilcox has written to The Children’s Trust expressing concerns the same could happen to another child. “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,” the coroner wrote.
In a prevention of future deaths report, Dr Wilcox highlighted efforts by Raihana’s mother to complain about the absence of one-to-one care, and the generic response given by The Children’s Trust; that neither Croydon Council or Raihana’s mother were told when a care home staff member was disciplined for leaving the youngster alone; and that concerns from Raihana’s mum were not passed on from care home managers to staff, despite multiple meetings.
Dr Wilcox also found that blame was initially directed at the wrong nurse, and that there were inconsistencies in the evidence given by another nurse – all of which should have been investigated properly by The Children’s Trust.
Raising ongoing concerns, the coroner said she feared children like Raihana may still be missing out on round the clock care, and that a ‘culture of cover up’ and ‘flawed investigation’ at The Children’s Trust may have pushed the blame onto an innocent individual while failing to highlight systematic failures, thereby losing the chance to learn from the incident.
Dr Wilcox also highlighted issues around communication, staff training, and prioritising admin tasks over care.
‘Raihana’s death was an avoidable tragedy’
Leigh Day partner Nandi Jordan, representing the family at the inquest, said: “We welcome the coroner’s thorough investigation into the circumstances of Raihana’s death and the finding that Raihana’s death was contributed to by neglect.
“In an inquest involving concerns with medical treatment it is rare for a coroner make findings of neglect. This reflects that that Raihana’s death was an avoidable tragedy and where there were substantial failures by multiple professionals and agencies involved her care.
“It is heart rending that none of the agencies responsible for Raihana’s wellbeing, where Raihana’s mum repeatedly raised concerns about the poor care and staffing levels took her concerns seriously. If they had Raihana would not have died.
“It is too late for Raihana, but we can only hope that the findings of this inquest act as a vehicle for much needed change with the agencies involved; firstly, to take carers’ concerns seriously when they advocate for their loved ones, and secondly, to ensure the care they are providing is safe for seriously disabled people who may not be able to advocate for themselves.”
‘We unreservedly apologise’
Mike Thiedke, Chief Executive, The Children’s Trust, said: “We were deeply saddened by Raihana’s unexpected death in June 2023 and the pain her loss has caused her family. On behalf of The Children’s Trust, we express our most heartfelt condolences to Raihana’s family.”
“The Coroner concluded that Raihana died of natural causes contributed to by neglect. 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. We unreservedly apologise to Raihana’s family for these failings.
“The Coroner issued The Children’s Trust with a Prevention of Future Death report on 7th May. We are carefully considering the report, and we will submit our response via the Coroner’s Office within 56 days of the date of the report being issued.
“Raihana’s mother raised serious concerns about her daughter’s care which were not acted upon or managed properly, and for that we are truly sorry. Her loss has had a profound effect on the way we care for, support, and involve the children and families we work with today.
“Actions we have taken following this heartbreaking experience include completing a thorough review of our care, substantial improvements to staff training, and putting in place a stronger system to make sure families are heard – especially when they raise concerns. 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.
“Our thoughts remain with Raihana’s family during this time.”
A spokesperson for Croydon Council said: “Our first thoughts are with Raihana’s family, and we want to express our deepest condolences for their devastating loss. Raihana was placed at The Children’s Trust so she could receive 24-hour care for her complex needs and we worked to ensure Raihanna’s mother was included in reviews, her voice was heard and any concerns addressed.
“Despite this, and the assurances we received from the Trust, it is clear that the care they provided fell below our expectations. Following internal reviews, the Trust have changed their processes around staffing and one-to-one care and we will continue to work with them to ensure that lessons have been learned from this tragedy.”
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