Mia Gauci-Lamport
14 Oct 2024 · Coroner Karen Henderson · Surrey
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate night monitoring of child with seizures
“Lack of appropriate monitoring of [the deceased] during the night”
2. inadequate medical care documentation and oversight
“Medical Care provided to [the deceased]”
3. failure of senior management to enforce robust care plan and governance
“Senior management, Children's Trust, Tadworth”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“That CNWL failed in its duty of candour in relation to provision of evidence in this case.”
This report
“delay in fulfilling the Duty of Candour' obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice.”
Closely relatedConfidence 0.80 · moderate
This report
“[the deceased]'s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard”
Later report
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
Responses
2024-0545-Response-from-CQC.pdf ↗· Tadworth Children's Trust
Stated action · await the outcome of Ofsted's inspection
“On 18th October 2023 CQC requested the outcome of the external investigation from the registered manager at TCT. This wasn't available, but TCT shared the findings with CQC of the internal investigation. Alongside the evidence of findings from the Ofsted inspection the CQC made the decision to await the external investigation findings before scheduling an inspection.”
2024-0545-Response-from-DHSC.pdf ↗· NHS England
Stated action
“the CQC inform us that they are monitoring the service to ensure that children residing there are not exposed to risk or unsafe care, which is of utmost importance so deaths such as [the deceased]'s can be prevented. CQC regulates the premises and the care provided, and they are reviewing any information received to help inform the next inspection.”
Stated action
“NHSE have provided assurance that their regional team has been working with system and other partners on responding to risks and concerns in a joint approach at this provider, which will be set out in their response.”
Stated action · 26 November
“The Government is supportive of the review on the duty it inherited from the previous administration and will consider the findings, recently published on 26 November, following a call for evidence in April this year. The government will consider these findings alongside findings from the ongoing manager regulation consultation as it continues to develop policy on candour in healthcare.”
2024-0545-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“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
“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
“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.”
Stated action
“Our NHS England Regional Medical Director has also offered to support with connecting TCT's clinical team to specialists within the NHS that can offer peer support and further improvement work.”
2024-0545-Response-from-The-Childrens-Trust.pdf ↗· Tadworth Children's Trust