Neglect at Children’s Trust care home in Surrey contributed to the death of 12-year-old Raihana Awolaja from Essex, coroner concludes

HM Senior Coroner for Inner West London, Professor Fiona Wilcox also accepted that there had been an arguable breach of Article 2 of the European Convention on Human Rights of the state’s operational duty to take measures to address a real and immediate risk to a person’s life.

The coroner found that 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, she had 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 by Croydon Borough Council at Tadworth Court in Surrey, a care home operated by The Children’s Trust.

The inquest heard Raihana’s mother, Latifat Kehinde Solomon had serious concerns about her daughter’s care at The Children’s Trust and had repeatedly found Raihana without one-to-one care during her visits.

Latifat recalled raising this potentially dangerous situation several times with Children’s Trust staff and Croydon Borough Council, but her 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 court 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.

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.

The court heard that paramedics were told that Raihana had been left unattended for 15 minutes.  

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

In her conclusion, the coroner said that there appeared to be confusion between Croydon Borough Council and The Children’s Trust as to the meaning of one-to-one care.

The inquest 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 during staffing breaks and twice daily shift handovers.

The coroner criticised the nursing staff involved, 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.

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

Nandi Jordan, 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.”

Counsel for the family is Darragh Coffey from 1 Crown Office Row.