Neglect at a Surrey children’s care home contributed to the tragic death of a 12-year-old girl, a coroner has found. Raihana Awolaja sadly died of natural causes contributed by neglect on June 1, 2023 at Tadworth Court care home.
Staff at a Surrey care home failed to give the 24-hour, one-to-one support Raihana needed because of her extensive health issues, according to the legal firm representing the family, Leigh Day.
Mike Thiedke, Chief Executive of The Children’s Trust, said: “We unreservedly apologise to Raihana’s family for these failings […] Raihana’s death has had a profound effect on the way we deliver care and work with families today at The Children’s Trust.”
Born prematurely at 27 weeks as a twin, Raihana was left with complex disabilities including being non-verbal and dependent on breathing through a tube in her neck. Raihana needed round the clock, one-to-one supervision to ensure her breathing tube did not get blocked, Leigh Day said.
But the coroner Professor Fiona Wilcox concluded there was confusion around the meaning of ‘one-to-one’ care between Croydon Council and The Children’s Trust.
The inquest heard the care home did not have enough staff available to consistently cover patients one-to-one. They were told individual staff members were regularly left caring for at least two patients at a time during staffing breaks and twice daily shift handovers.
Prof Wilcox criticised the nursing staff involved, as she found it was likely had Raihana been properly observed, the deterioration in her condition would have been identified and her life saved.
Raihana was a looked-after child under the council’s care due to her extensive needs. In 2022, she was placed by Croydon Council at Tadworth Court in Surrey, a care home operated by The Children’s Trust.
Raihana’s mother, Latifat Kehinde Solomon, had serious concerns about her daughter’s care at The Children’s Trust, the inquest heard. Ms Soloman claimed she had repeatedly found Raihana without one-to-one care during her visits.
Ms Soloman said she flagged this potentially dangerous situation several times with Children’s Trust staff and Croydon Council. Despite her concerns, she said nobody did anything.
Nandi Jordan, who represented Raihana’s family during the hearing, said it is “rare” for a coroner to find neglect in an inquest for medical treatment. She said the conclusion reflects that Raihana’s death was “an avoidable tragedy” and there were “substantial failures by multiple professionals and agencies involved in her care”.
Records show, on the evening of Monday, May 29, 2023, the nurse responsible for Raihana started her shift and checked the 12-year-old’s chart. The inquest heard that despite Raihana appearing more tired than usual the nurse chose not to monitor her oxygen levels. Instead, the nurse left and went to another building to complete some admin work.
The nurse asked a colleague to observe Raihana but no one seemed available, so she was actually left on her own. Records show when the nurse returned from her admin task, she found Raihana in cardiac arrest, a Leigh Day spokesperson said.
Staff performed CPR and called an ambulance. The court heard that paramedics were told Raihana had been left unattended for 15 minutes. Raihana was taken to St George’s Hospital, in Tooting, London. But sadly, three days later, she died.
The Chief Executive of The Children’s Trust, said: “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.
“Following this heartbreaking experience, we have increased frontline staffing levels and changed how we monitor and observe children and young people in partnership with our regulators and the wider health care system.
“On behalf of The Children’s Trust, we express our most heartfelt condolences to Raihana’s family and acknowledge how difficult the inquest must have been.”
Ms Jordan, from Leigh Day said: “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.”
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 Raihana’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.”
