Coroner flags same concern after second death at trust

A coroner has called for action following a teenager's inquest just months after the trust facility she lived at was warned about "inconsistent" checks.

Mia Gauci-Lamport was found unresponsive in bed at Tadworth Children’s Trust (TCT) in September 2023.

The 16-year-old had Ohtahara syndrome, a rare form of epilepsy, and was meant to be checked every 15 minutes by carers.

Surrey assistant coroner Karen Henderson has issued a prevention of future deaths (PFD) report after hearing that checks did not happen as frequently as required.

Dr Henderson said Mia, who required full-time residential care, died of natural causes.

She added: "The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the inquest touching on the death of Connor Wellsted at TCT in 2022."

Six months after Mia's death a Care Quality Commission inspection found the facility carried out "inconsistent" visual checks during overnight observations.

The trust said it was considering the coroner's recommendations and was committed to learning, creating a safe environment and delivering high quality services.

The coroner said it was common practice for some staff to review images from a video monitor placed above Mia's cot, despite it being recognised that this was "insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation".

Mia's medical records were also "neither comprehensive nor easy to understand and did not conform to the expected standard", the report added.

Dr Henderson said: "There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs."

Mia, who had received care at the trust since July 2020, was reviewed by a privately-funded consultant when requested by TCT's medical staff.

The report said the consultant had no terms of reference, did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control.

Due to financial constraints, the consultant’s service level agreement was temporarily terminated and unavailable from April-October 2023.

The coroner said Mia was also not under a specialist NHS paediatric neuro-consultant to ensure her medical needs followed expected practices.

The trust said: "We are carefully considering the recommendations made by the coroner, together with our own independent investigations conducted since Mia’s sad death.

"We are determined to work together with all relevant authorities to understand any lessons we can learn."

The NHS said it was considering the report and would respond in due course.

The Department of Health and Social Care has been contacted for a comment.