Coroner warns potential “culture of cover up” could lead to more deaths after 12-year-old Raihana Awolaja died at a Children’s Trust residential care facility in Surrey

The Senior Coroner for Inner West London, Professor Fiona Wilcox has issued a prevention of future deaths report addressed to The Children’s Trust’s Chief Executive, raising concerns that severely disabled children may not be receiving the level of care needed to keep them safe. The charity operates what it describes as the UK's largest paediatric brain injury rehabilitation service at its national specialist centre at Tadworth Court, Surrey.

Raihana died of natural causes on Thursday 1 June 2023 contributed to by neglect. This followed a breakdown of the 24-hour, one-to-one care that she was supposed to be receiving, the coroner concluded following a three-day hearing at Inner West London Coroner’s Court.

Raihana was born on Wednesday 9 March 2011 in Romford, Essex. She was one of twins, born at 27 weeks. As a result of her premature birth, Raihana was left with complex disabilities.

Raihana was a looked-after child under local authority care due to her extensive health needs which included being non-verbal and dependent on a tracheostomy tube to breathe. She required constant one-to-one supervision to ensure her breathing tube did not become blocked.

In 2022, Raihana was placed at Tadworth Court in Surrey, a residential care facility operated by The Children’s Trust.

The inquest heard Raihana’s mother, Latifat Kehinde Solomon had serious concerns about her daughter’s care and that Latifat had repeatedly found Raihana unsupervised during her visits. This was raised several times with the Children's Trust and Croydon Borough Council including in written complaints providing detailed examples, however Latifat’s concerns were not acted upon.

On the evening of Monday 29 May 2023, records showed that the nurse responsible for observing Raihana started her shift and checked Raihana’s chart. The inquest heard that despite Raihana appearing more tired than usual, the nurse chose not to monitor her oxygen levels and instead, left and went to another building to complete some admin work. The inquest was told that the nurse asked a colleague to observe Raihana, but their shift had ended. The inquest heard that this colleague then asked another staff member to look after Raihana, but that Raihana was in fact left on her own.

Raihana was left for approximately 15 minutes, during which time her tracheostomy tube was blocked by secretions.  With no carer present to clear the tube, Raihana suffered respiratory compromise and arrested.

Following CPR, Raihana was transferred to St George’s Hospital, in Tooting, London. Three days later, on Thursday 1 June 2023 she died.

HM Senior Coroner for Inner West London, Professor Fiona Wilcox has given the Chief Executive of the Children’s Trust 56 days from Wednesday 30 April 2025 to respond to the following concerns:

• “That children such as Raihana requiring one to one care are still at times receiving less intensive care and supervision than they require.  
• “That there may be culture of cover up at Tadworth Children’s Trust, 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.  
• “That Tadworth Children’s Trust do not sufficiently communicate with the commissioning local authority nor next of kin in relation to issues with care and supervision, for example not informing the named social worker nor the mother of the disciplinary proceedings against a staff member who left Raihana alone. This in turn leaves vulnerable residents at risk, as the named social workers and possibly the commissioning authority nor the next of kin will be aware of potential increased risks to the vulnerable child. 
• “That there may be staff training issues in relation to what one to one care means in practice. 
• “That there may be training issues in relation to the prioritisation of administrative tasks above care.  
• “That next of kin are not sufficiently listened to when they raise concerns, and their complaints are dismissed without sufficient investigation.  
• “That the systems of communication between those attending planning and review meetings and those providing care to the residents are inadequate, such that matters raised at these meetings and any actions agreed to address them are insufficiently communicated to those providing care to the residents.”

The coroner says the response “must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you (The Children’s Trust, Chief Executive) must explain why no action is proposed.”

Raihana’s family are represented by Nandi Jordan, a partner in the medical negligence team at Leigh Day.

Nandi Jordan said:

“We are grateful for the coroner’s careful consideration of this case. We share the coroner’s concerns about the care being provided to disabled children by the Children’s Trust. Sadly, Raihana’s mother knew the care Raihana was receiving was inadequate and raised her concerns that the placement was unsafe both with the Children’s Trust and also to Croydon Borough Council who were responsible for Raihana as a looked after child, but these were not acted upon. As a result of the failings that the coroner has identified in this case a 12-year-old child has needlessly died”.