Four nurses investigated over death of boy, 5, at flagship children's care home
Four nurses are facing a fitness to practise probe after the death of a 5-year-old boy at a flagship care home for disabled children, The Independent can reveal.
The Nursing and Midwifery Council (NMC), the UK's nursing watchdog, initially found there was no case to answer over the death of Connor Wellsted, who suffocated in his cot in 2017 while being cared for at The Children's Trust (TCT) in Tadworth, Surrey.
The nurses were referred to the NMC in May 2022, but the watchdog later closed the investigations. It reopened the probe in November 2023 and, this month, after a 19-month-long investigation, decided all four nurses should face fitness to practise tribunals.
No interim conditions have been placed on the nurses, meaning they can continue to work while awaiting the outcome. If the committee finds the nurses are unfit to practise, they could be struck off or suspended. However, the committee can also decide that the nurses' fitness to practise is not impaired and give no sanction.
It comes after The Independent revealed that Surrey police had reopened a probe into the handling of Connor's death following a litany of failings over the little boy's care.
Connor died at TCT, the UK's largest brain injury rehabilitation centre for children, which can care for up to 66 young people, having suffocated when a cot bumper became lodged under his chin. He had been there for six weeks, receiving care for neuro-rehabilitation.
He was the first of three disabled children to die while in the care of TCT. Raihana Oluwadamilola Awolaja and Mia Gauci-Lamport died in June and September 2023, respectively.
Multiple failings have been identified in all three of the children's care, including a failure to appropriately monitor them.
In 2022, coroner Karen Henderson found Connor died after the cot bumper, which was not properly secured, came loose and obstructed his airway.
The inquest found TCT 'failed to keep Connor safe in his cot.'
Among concerns highlighted by the inquest was the fact Connor had 'no regular or direct supervision during the night'.
The inquest also revealed staff did not fully inform the police and coroner's services as to the circumstances of his death.
Police were not told of the position Connor was found in, and that he had been dead for some time. They were also not told that the padded cot bumper was initially found across his neck, the inquest heard.
The prevention of future deaths report states TCT's chief nurse and medical director were concerned about the role the bumper played in his death, but they did not keep a copy of his medical records or inform the relevant statutory bodies and 'arguably misled' the CQC.
The pathologist was also not informed of the circumstances of his death, which prevented a post-mortem examination from taking place to establish whether the cot bumper played a part in how he died, the report said.
'An innocent individual'
Last month, Coroner Fiona Wilcox issued a prevention of future deaths report following the death of Raihana. The report found there was a 'gross failure in care by nursing staff' after they failed to adequately observe her.
It is not known whether any of the same staff cared for both Connor and Raihana.
The inquest also revealed: 'Following Raihana's death, TCT undertook an investigation which failed to uncover what had happened or to understand the cause of her death. This meant that a nurse, to whom Raihana's care had been handed to by the allocated carer was blamed by the TCT and was referred to the NMC erroneously.'
TCT said the initial investigation had been carried out by an external organisation.
The inquest also found 'issues with the credibility of another nurse (nurse two) who should have been caring for Raihana'.
Ms Wilcox warned: 'There may be a culture of cover-up at the TCT, 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.'
In response to the coroner's allegations about the erroneous referral to the NMC, TCT said: 'We accept that the initial external investigation was inadequate and did not sufficiently explore systemic factors.
'We later identified these issues and undertook further work to strengthen our organisational learning. The extensive evidence presented to the coroner during the inquest helped clarify the events that led to Raihana's death and enabled us to improve the way we manage and investigate incidents.
'Raihana's death has prompted significant reflection, change, and action across our organisation. We are working hard to build a no-blame culture and support our specialist staff to meet our high standards of care. We've made significant changes to how we review and respond to concerns - focusing on learning, not blame.'
It said it has implemented the Patient Safety Incident Response Framework (PSIRF), 'which shifts the emphasis from individual fault to understanding wider systemic issues'.
The NMC was sent a copy of Raihana's prevention of future deaths report. In a response to The Independent, it said: 'We are aware of the tragic deaths of Connor, Raihana and Mia and our thoughts are with their loved ones.
'We can confirm that we have received the prevention of future deaths report in relation to Raihana's sad death and are considering the appropriate next steps.
'We are only able to confirm whether an individual is under investigation in certain circumstances, which is generally if we have completed an investigation and case examiners decide there is a case to answer.'
The NMC confirmed that, in the case of Connor, its case examiners have decided there is a case to answer concerning four registrants and have recommended they proceed to a fitness to practise committee.
The NMC has faced criticism over the screening and decision-making of referrals.
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