Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate medical documentation oversight
The earlier warning
Mia Gauci-Lamport · 14 Oct 2024 · Karen Henderson, Surrey
“[the deceased]'s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard”
judiciary.uk/…/mia-gauci-lamport-prevention-of-future-deaths-re…
What was promised
Stated action 1 · response to Mia Gauci-Lamport (14 Oct 2024) · stated timescale: none stated
“A recent RQR meeting with TCT has resulted in an agreed plan for them to adopt the national paediatric early warning system (PEWS).”
Stated action 2 · response to Mia Gauci-Lamport (14 Oct 2024) · stated timescale: none stated
“TCT agreed to further their connections within the local integrated care system and with tertiary care providers to improve flow to clinical appointments.”
Stated action 3 · response to Mia Gauci-Lamport (14 Oct 2024) · stated timescale: none stated
“The acute trust paediatric nursing colleagues involved in the RQR meeting were positive about the steps TCT had taken so far to review and audit observations and monitoring.”
5 further stated actions are listed on the full chain page.
What recurred
- 28 May 2026 · Lacey Heath · Sonia Hayes · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Mia Gauci-Lamport · 14 Oct 2024
“[the deceased]'s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard”
Later · Lacey Heath · 28 May 2026
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
What happened next
No web check of the stated actions has been published for this chain.