Connor Wellsted

CQC response to Regulation 28 report – Action to Prevent Future Deaths 

Report by 
To Dr Karen Henderson, HM Assistant Coroner for Surrey 
In respect of the inquest of Connor Wellsted 

Report details 

Background 
I have prepared this report in respect of the Regulation 28 report – Action to Prevent 
Future Deaths, received 17 May 2022 – relating to the death of Connor Wellsted on 
17 May 2017.  

I have been asked to do so in order to outline the action proposed, or taken, by the 
Care  Quality  Commission  (‘the  CQC’)  with  responsibility  for  the  regulated  activity 
Treatment  of  Disease,  Disorder  and  Injury  (TDDI)  in  Children’s Homes,  including 
The Children’s Trust (TCT) where Connor died. 

I am employed as an interim Children’s Services Inspection Team Manager in the 
National Operations Directorate of the CQC. 

This  response  will  explain  the  actions  already  taken  by  the  CQC  and  explain  the 
rationale for no further action being taken. 

The coroner’s concerns in section five on page two of the Regulation 28 report are 
as follows: 

1.  The cot 
2.  Monitoring of Connor during the night 
3.  Probity and Investigation by the Children’s Trust – Tadworth 
4.  Senior management, Children’s Trust - Tadworth 

The cot 

The R28 report states: 
‘The cot Connor’s was allocated was nine years old, used infrequently and had not had a 
yearly servicing for the previous five years. There was no guidance or clarity as to how the 
padded boards/cot bumper should have been placed around the wooden frame of the cot 
in circumstances whereby the foster parents did not wish the cot to be padded. 

It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was 
inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge 
was without Velcro it could not have been attached to the cot leaving it loose with the result 
that it dislodged entrapping Connor across his neck.’ 

The CQC response: 
The cot used for Connor during this admission was not a standard piece of equipment used 
by staff at TCT and they were unfamiliar with its use. This type of cot is no longer in use at 
TCT and all specialist cots have been replaced with equipment compliant with current bed 
standards. (BS EN 50637:2017 – Medical electrical equipment – Particular requirements for 
the basic safety and essential performance of medical beds for children). 

20220627_The Children’s Trust_Reg 28_response to coroner_final 

1 

 
 
 
 
 
 
 
 
 
 There was also evidence of staff failing to follow the care plan which stated to use the cot 
without the padded bumpers, in line with the foster carers’ wishes and to allow for maximum 
visibility for both Connor and staff, as three of the bumpers remained in situ. One of the 
recommendations from the root cause analysis (RCA) was regarding the implementation of 
care plans and the stipulation to discuss with the shift leaders if there were concerns around 
the adherence by staff to any instructions in the care plan.  

Since then, there have been a small number of incidents resulting from care plans that have 
not been fully adhered to, that have been appropriately notified to the CQC. We have seen 
evidence where proper investigation and action has been taken by TCT on each occasion, 
including staff being required to write reflective accounts, undergo additional training and/or 
a period of observed practice, and where necessary, disciplinary action.  

The CQC have carried out three inspections of TCT since Connor’s death as follows: 
•  November 2017 – this was a comprehensive unannounced inspection looking at all five 
key questions of whether TCT is Safe, Effective, Caring, Responsive and Well-led. We 
rated outstanding by the CQC’s Adult Social Care team. 
January 2020 – comprehensive announced inspection looking at all five key questions 
of whether TCT is Safe, Effective, Caring, Responsive and Well-led. This inspection was 
carried  out  by  the  CQC’s  Children’s  Services  Inspection  Team  and  was  aligned  with 
Ofsted. Both the CQC and Ofsted rated outstanding.  

• 

•  May  2021  –  targeted  unannounced  inspection  by  the  CQC’s  Children’s  Services 
Inspection  Team  looking  at  the  key  question  of  whether  TCT  is  Safe,  there  was  no 
change to the rating. 

Audits and children’s records were reviewed in all three inspections and we did not find any 
evidence  of  care  deviating  from  that  stipulated  in  care  plans.  We  saw  examples  of  how 
learning from audits was shared with multi-disciplinary staff across all seven houses.  

Monitoring of Connor during the night 

The R28 report states: 
‘Connor had no regular or direct visual supervision during the night (other than to open the 
door of his room to check if there was a smell) despite the request of his foster parent to 
check in circumstances whereby in other parts of the Trust regular visual inspection was 
the norm.’ 

The CQC response: 
The RCA shared with the CQC states that Connor was not observed overnight when at home 
and he was assessed by the multi-disciplinary team at TCT on admission, as being physically 
and medically well. This led to the decision that there was no clinical indication for overnight 
observations. The needs of the children staying in different parts of TCT vary. For example, 
Chestnut  House  cares  for  children  with  the  most  complex  of  needs,  including  medical. 
Connor was placed in Maple House for his rehabilitation and did not have any medical needs 
at that time. 

TCT have introduced a clear and comprehensive Sleep Monitoring Policy, which was signed 
off and implemented in 2018 and updated in 2019. The policy has been further updated 
and renamed Frequency of Monitoring and is due to be signed-off in July 2022. Records 
reviews  during  each  of  the  inspections  indicated  staff  understanding  of  the  policy  and 
adherence in children’s care plans where the requirement of overnight monitoring is based 
on clinical need and individualised to each child. 

20220627_The Children’s Trust_Reg 28_response to coroner_final 

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 TCT have taken action in relation to overnight monitoring  appropriate to what we would 
expect of them.  

Probity and Investigation by the Children’s Trust - Tadworth 

The R28 report states: 
‘The Police and the coroner’s service attending the Trust shortly after being informed of 
Connor’s death were not fully informed of the circumstances of his death. The scene had 
not been preserved. They were not told of the position Connor was found, that he had been 
dead for some time (likely hours) or that the padded board was initially found across his 
neck and that it required force by either one or two nurses for it to be pushed down to be 
removed. 

Connor’s death was sudden and unexpected, and the senior management of the Trust (chief 
nurse and medical director) were concerned at the time the role the padded board may 
have played in Connor’s death. However, they did not keep a copy of Connor’s medical 
records, nor did they undertake their own initial internal enquiries, or inform the relevant 
statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the 
circumstances of Connor’s death. 

Likewise, the pathologist who undertook the autopsy on Connor was not informed of the 
circumstances of his death thereby preventing a forensic post-mortem to have taken place 
to establish the role the cot bumper may have played in his death. In addition, the Trust 
engaged an expert opinion from a forensic pathologist without fully informing him of the 
position the cot bumper may have played in Connor’s death. 

The Trust undertook several Serious Investigation reports, the first of which was six months 
after Connor’s death. These reports did not acknowledge or address the role the cot bumper 
may have played in Connor’s death despite evidence from multiple witnesses indicating it 
was likely to be significant.’ 

The CQC response: 
The  statutory  notification  shared  with  the  CQC  on  the  day  Connor  died,  described  his 
position in the cot and stated that the padded bumper was found against his chest, rather 
than his neck. 

A discussion between the registered manager of TCT and the CQC relationship owner in the 
Adult Social Care directorate suggests the decision to delay the initiation of the RCA was 
deliberate and was documented as follows: 
‘I called 
the RM at the service. HD states that yesterday they had the 
documents back from the coroner’s office so expects a conclusion from the coroner’s office 
shortly. In the meantime, as they now have the documents needed, they will start the 
internal investigation.’  

The internal root cause analysis report concluded on 20 December 2017 and identified a 
number of actions to address weaknesses in practice. Improvements in these areas were 
evident  at  the  subsequent  comprehensive  inspections.  As  identified  in  the  coroner’s  R28 
report, the RCA did not consider the cot bumper as a causative factor in Connor’s death. 
The  lessons  learned  and  recommendations  were  predominantly  regarding  overnight 
observation. 

20220627_The Children’s Trust_Reg 28_response to coroner_final 

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 All statutory notifications received  by  the  CQC  from TCT  since I became the relationship 
owner in 2018, have been followed up with appropriate and robust investigation reports, 
complete with details of actions taken and improvements made. 

Senior management, Children’s Trust - Tadworth 

The R28 report states: 
‘The current senior management team have not acknowledged there was a lack of 
transparency and openness as to how Connor died, or that the Trust did not properly 
investigate his death or inform the relevant statutory bodies of the circumstances of his 
death giving rise to concern 
of an ongoing lack of insight that institutional learning around serious incidents has not 
been accepted by the Trust. 

As a consequence, there is a need to introduce and develop robust clinical governance 
processes and systems to reassure the public and supervisory statutory bodies that they 
will be informed of any future adverse events and they will be investigated with openness, 
candour and transparency.’ 

The CQC response: 
We have seen evidence in monitoring and engagement work, as well as during inspection 
activity, of a learning culture at TCT. Recommendations made in the 2020 report had been 
implemented at the time of the unannounced targeted inspection in 2021. Since becoming 
the  relationship  owner  in  2018,  the  senior  leadership  team  at  TCT  have  always  been 
receptive and responsive to challenge and proactive in providing information to demonstrate 
how  improvements  have  been  made  in  response  to  incidents,  complaints  and  inspection 
findings. 

The latest comprehensive inspection in January 2020 found the following: 

‘There was an open and transparent culture amongst staff and leaders to identify, report 
and learn from incidents and near misses. Incident reports were detailed, and investigations 
were thorough with clear analysis and action planning as a result. 

Lessons learned were shared with all staff and houses meetings, team away days and a 
monthly governance blog on the intranet. A tracker was in place to monitor when actions 
were completed and by whom. This demonstrated a commitment for staff and leaders to 
continually improve and make the service as safe as possible for children and young people. 

Governance  structures,  accountability  frameworks  and  monitoring  of  quality  and 
improvement was strong and well-embedded throughout the service. Staff and leaders at 
both strategic and operational levels regularly asked themselves, and each other, the five 
key questions about whether their service was safe, effective, caring, responsive and well-
led. We saw good evidence of challenge and seeking assurance to maintain excellence and 
continually improve. 

The service demonstrated well how they strived for continual improvement. They had a 
comprehensive audit plan which included external as well as internal audits. Areas regularly 
audited  included  clinical,  medical  and  psychosocial  audits  including  safeguarding, 
supervision, care plans and medicines management. Audits were generally very effective in 
driving progress. Medicines audits, however, were not always effective in highlighting areas 
for improvement, such as oxygen storage and person-centred PRN protocols.  

20220627_The Children’s Trust_Reg 28_response to coroner_final 

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 We saw significant evidence demonstrating the strong culture of learning and how well the 
service learned from feedback, complaints, and incidents. Feedback from children, young 
people and their families was actively sought, including through the young person's 
participation group and the friends and family test (FFT). We saw how staff and leaders 
were proud of the excellent care they provided to children and were keen to identify how 
they could do even better. The quality improvement lead was developing an adapted version 
of the FFT specifically for children and young people to complete, which will be in place by 
April 2020. This will give children and young people another opportunity to have their voices 
heard.’ 

Final comments 
The report following the inspection in November 2017 can be accessed  by the following 
link: The Children's Trust_November 2017 report  

The report following the inspection in January 2020 can be accessed by the following link: 
The Children's Trust_Jan 2020 report  

The report following the inspection in May 2021 can be accessed by the following link: The 
Children's Trust_May 2021 report  

The inspections completed in the five years since Connor’s death, as well as the information 
available regarding TCT’s response to incidents, events and complaints, have all identified 
safe practice and good leadership and governance. The CQC have not found any evidence 
to  suggest  that  the  concerns  raised  in  the  Regulation  28  report,  remain  as  concerns, 
regarding current leadership, governance or practice. 

The  CQC  will  continue  to  monitor  and  inspect  according  our  published  inspection 
methodology and continue to respond to any emerging risk identified through notifications 
or whistleblowing reports. 

Signed: 

Name: 
Authorised by: 
Dated: 

27 June 2022 

 interim Children’s Services Inspection Manager 

 Deputy Director of Multi-agency Operations 

20220627_The Children’s Trust_Reg 28_response to coroner_final 

5

From Helen Whately MP 
Minister of State for Social Care 
39 Victoria Street 
London 
SW1H 0EU 
020 7210 4850 

19 January 2023  

Dr Karen Henderson  
HM Assistant Coroner for Surrey  
HM Coroner’s Court Surrey  
Station Approach  
Woking  
GU22 7AP  

Dear Dr Henderson,   

Thank you for your letter of 15th May 2022 about the death of Connor Samuel Timothy 
Wellsted. I am replying as the Minister responsible for Social Care, and I thank you for 
additional time allowed. 

Firstly, I would like to say how saddened I was to read of the circumstances of Connor’s 
death, and I offer my sincere condolences to his family and loved ones.  The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention. 

In preparing this response, Departmental officials have made enquiries with NHS England as 
well as the relevant regulator in this instance, the Care Quality Commission.  I am further 
advised that the Children’s Trust have also provided a detailed response to your report. 

I am sorry that Connor was not provided the care that he needed to him safe.  The 
Children’s Trust’s have now updated their Medical Devices and Equipment Policy and staff 
are now trained in the appropriate use of clinical assets, including padded cots.  It is also 
now mandatory for nursing and care staff at the Trust to carry out checks on equipment 
twice within a 24-hour period.  They have also updated their Sleep Monitoring Policy and a 
mandatory risk assessment, co-signed by the parent, is completed when a child or young 
person is admitted to the Trust.  The policy mandates visual monitoring of the patient and 
that a 24-hour sleep monitoring chart must be completed, indicating when a visual inspection 
was performed.    

I understand the Trust have developed their policies and protocols for responding to medical 
emergencies and sudden unexpected deaths, including updating the sudden death policy to 
include the need to preserve the scene and quarantine equipment. They have also 
undertaken to ensure any future investigations into unexpected deaths are conducted with 
honesty, openness and full transparency, in a timely manner and in accordance with 
statutory guidance and best practice. The Senior Leadership Team and Board of Trustees 
understand their statutory duties and the role they are expected to play in the investigation of 
any future sudden unexpected deaths, exhibiting openness, transparency and probity while 
promoting an open and clear learning culture at all levels for dealing with serious incidents. 

 
 
  
 
  
  
  
  
  
  
  
  
  
 
 
 In addition to this, NHS England have made sure that all relevant policy teams who are 
responsible for policy setting and transformation in areas such as Specialised 
Commissioning and the Children and Young people Programme were aware of your report 
and the concerns raised.  They have also met with representatives from a variety of teams to 
ensure they are aware of the guidance: ‘Bed rails: Management and Safe Use’.1 

Further, the Children’s Trust learnings are being reflected in the protocol they are developing 
in line with the Royal College of Pathologists guidance: ‘Sudden unexpected death in infancy 
and childhood: Multi-agency guidelines for care and investigation’2 and current statutory 
guidance.  The CQC have advised that such learnings were evident at their subsequent 
comprehensive inspections of the Trust.  The CQC have also confirmed that all statutory 
notifications received by the CQC from the Children’s Trust since 2018 have been followed 
up with appropriate and robust investigation reports, complete with details of actions taken 
and improvements made. 

Finally, I am aware that the Trust’s senior leadership team has established a learning action 
group that is dedicated to developing new processes and systems that will address your 
concerns and will build upon the improvements the Trust has made over the last five years.  

Yours sincerely, 

HELEN WHATELY 

1 https://www.gov.uk/guidance/bed-rails-management-and-safe-use  
2 https://www.rcpath.org/uploads/assets/874ae50e-c754-4933-995a804e0ef728a4/Sudden-
unexpected-death-in-infancy-and-childhood-2e.pdf  

1

Dr Karen Henderson 
HM Assistant Coroner for Surrey 
HM Coroner’s Court Surrey 
Station Approach 
Woking 
GU22 7AP 

National Medical Director 
NHS England 
Wellington House 
133-155 Waterloo Road 
London 
SE1 8UG 

18 October 2022 

Dear Dr Henderson 

Re: Regulation 28 Report to Prevent Future Deaths – Connor Samuel Timothy 
Wellsted who died on 17 May 2017. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 May 
2022 concerning the death of Connor Samuel Timothy Wellsted on 17 May 2017. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deepest condolences to Connor’s  family and loved ones and I am very 
sorry to hear about the tragic circumstances of Connor’s death. NHS England are keen 
to assure the family and the Coroner that the concerns raised about  Connor’s  care 
have been listened to and reflected upon, in the hope that an incident such as this one 
never occurs again. 

I am grateful for the further time granted to respond to your Report, and I apologise to 
the family for the delay, as I appreciate this will have been an incredibly difficult time 
for them. 

Following  the  inquest,  you  raised  concerns  in  your  Report  relating  to  the  following 
issues: 

1.  The cot itself; 
2.  Monitoring of Connor during the night; 
3.  Probity and investigation by the Children’s Trust, Tadworth; and 
4.  Senior  management  at  the  Children’s  Trust,  Tadworth  (including  the  lack  of 
transparency  and  openness  around  the  circumstances  of  Connor’s  death, 
which  were  not  properly  investigated  or  notified  to  the  relevant  statutory 
bodies). 

As a consequence of the above, your Report raised that there was a need to introduce 
and develop robust clinical governance processes and systems, to reassure the public 
and  supervisory  statutory  bodies  that  they  will  be  informed  of  any  future  adverse 
events and that they will be investigated with openness, candour and transparency. 

The role of NHS England (NHSE) regarding your Report has been to seek assurance 
that  all  relevant  NHSE  policy  teams  who  are  responsible  for  policy  setting  and 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
  
 
 
 
 transformation in those areas (such as Specialised Commissioning and the Children 
and Young people Programme) were aware of this Report and the concerns raised. 
The team investigating and drafting this response have met with representatives from 
a variety of teams that cover this domain of healthcare. We have  also ensured that 
they are aware of the new guidance on beds and cots  ‘Bed rails: Management and 
Safe Use . 

Further, your Report has been shared with the NHSE Regulation 28 Working Group, 
who in turn have shared the Report with their regions through their mortality working 
groups,  whose  membership  includes  Integrated  Care  Systems  (ICSs).  ICSs  are 
partnerships of organisations that come together to plan and deliver joined up health 
and care services, and to improve the lives of people who live and work in their area. 
ICSs are responsible for providers within their area and are able to check that they are 
adhering to guidance which could prevent future deaths. 

The  Medicines  and  Healthcare  products  Regulatory  Agency  (MHRA)  regulates 
medicines, medical devices and blood components for  transfusion in the UK. Beds, 
bedrails and cot sides are included in their remit. Patient Safety Incidents around the 
use  of  bedrails  /  cots  and  padded  bedrails  were  reviewed  by  NHS  Improvement  in 
October 2017 and March 2018, in their Patient Safety Review and Response Report 
(see  page  18).  The  report  was  shared  with  MHRA,  Medical  Device  Safety  Officers 
(MDSOs), and the National Association for Safety and Health in Care Services. As a 
result, MHRA were asked to consider the issue of padded bedrail  bumpers/sides in 
their ‘Bed rails: Management and Safe Use guidance. This guidance now contains a 
section  on  ‘Inflatable  bed  sides  and  bumpers’  (see  section  6,  case  study  6).  This 
section states that it is “important not to change the mattress or bed rails from the size 
or specification recommended by the manufacturer, to avoid creating entrapment gaps 
and  instability”. This  aligns with  The  Children’s Trust’s response  dated  8  July 2022, 
where they state that “The new beds have built in cot sides and padding, integral to 
the bed rather than separate bumpers”. 

In  terms  of  investigation,  the  NHS  England  Patient  Safety  Incident  Response 
Framework in July 2022. The Patient Safety Incident Response Framework (PSIRF) 
sets  out  the  NHS’s  approach  to  developing  and  maintaining  effective  systems  and 
processes for responding to patient safety incidents, for the purpose of learning and 
improving  patient  safety.  The  PSIRF  is  a  contractual  requirement  under  the NHS 
Standard Contract, and as such is mandatory for services provided under that contract 
and will include Providers such as The Children’s Trust at Tadworth Court. 

I note that you also sent your Report to the Chief Executive and Medical Director of 
the Children’s Trust, Tadworth, and I have had sight of their response as referred to 
above. On 15 July 2022, representatives from the South East Region attended upon 
the Trust and carried out a comprehensive review of all of the points that you made in 
your  Report.  They  concluded  that  there  were  no  current  quality  concerns,  however 
there  was  room  for  improvement.  The  outstanding  actions  for  improvement  will 
continue to be monitored by NHS England South East. I am assured that the Children’s 
Trust, Tadworth, have addressed all of the concerns raised in your Report. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 I would also like to provide further assurances on the national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around events, such as the sad death of Connor, are shared across the 
NHS at both a national and regional level and helps us to pay close attention to any 
emerging trends that may require further review and action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

8th July 2022 

Private and Confidential 

Dr Karen Henderson  
HM Assistant Coroner 
Surrey Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

Dear Dr Henderson, 

We are writing to set out our formal response to the report made under paragraph 7, Schedule 5, of the 
Coroners and Justice Act 2009 and regulations 28 and 29 of the  Coroners’ (Investigations) Regulations 
2013, dated 15 May 2022, which was issued following the inquest into the death of Connor Wellsted. 

We  would  like  to  begin  by,  once  again,  extending  our  deepest  condolences  and  sincere  apologies  to 
Connor’s family.  Our charity exists to help children like Connor live their best life possible and so it is the 
deepest regret of our senior leadership team and board of trustees that we failed to do so.  We know this 
has been an extremely difficult time for Connor’s family, including his foster carers, and that they have 
had to wait a long time for answers.   Whilst no words can ever bring Connor back, we hope that this 
response illustrates how very seriously we take the family’s loss and the rigour with which we have taken 
actions from the lessons learnt to ensure that something like this can never happen again. 

We have put in place extensive measures and improvements over the last five years, and we are confident 
that these measures are robust and effective.  Concerns raised in the regulation 28 report, with regards 
to the prevention of future deaths, relate to issues we have addressed during the significant passage of 
time since Connor's death, as heard in evidence at the inquest. The coroner has not raised any concerns 
about  the  adequacy  of  the  measures  we  have  put  in  place.  Nevertheless,  in  the  first  section  of  this 
response we set out the actions we have already taken and summarise the evidence heard at the inquest 
about the changes implemented from the lessons learnt. 

Aside  from  the  concerns  directly  linked  to  preventing  future  deaths,  the  coroner  has  included  other 
concerns  in  her  report  which  deal  with  our  immediate  response  to  Connor’s  death,  the  subsequent 
internal  investigation  and  questions  of  transparency  and  probity.    We  take  these  other  concerns 
extremely seriously and the second section of this report sets out our response to these concerns as well 
as the actions we are taking.  

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

1.0 

Action to Prevent Future Deaths    

This section sets out in detail the actions we had already taken, prior to the inquest, to prevent future 
deaths and which were outlined in the evidence before the coroner at the inquest.  Whilst we are never 
complacent and always look to improve our processes and controls, we believe the steps we have taken 
are robust. We have, for example, undertaken external benchmarking of our sleep monitoring practices 
to assure ourselves of this.  It should also be noted that our services have been inspected and rated five 
times by the Care Quality Commission (CQC) and Ofsted Care since Connor’s death with the following 
outcomes: 

•  CQC January 2018 and March 2020 – “Outstanding” on both occasions. 
•  Ofsted Care January 2020 and August 2021 – “Outstanding” and “Good” respectively.  At the time 
of writing, we are awaiting the rating following Ofsted’s most recent inspection of our care services 
in May 2022. 

Concern 
1.1 The cot  

“The cot Connor’s [sic] was allocated was nine years old, used infrequently and had not had a yearly 
servicing for the previous five years. There was no guidance or clarity as to how the padded boards/cot 
bumper should have been placed around the wooden frame of the cot in circumstances whereby the 
foster parents did not wish the cot to be padded.  

It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately 
and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could 
not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor 
across his neck.“ 

Response  

Type of cot 
During the course  of  the  inquest into Connor’s death,  the coroner  heard evidence  from the  former 
director of clinical services (chief nurse), and the current medical director of The Children’s Trust, in 
respect  of  the  measures  we  have  implemented  to  ensure  the  safety  of  sleeping  equipment.    We 
stopped using the specific type of cot allocated to Connor in October 2017.  All our bed supports and 
sleeping systems are assessed and recommended by qualified practitioners.   

During December 2020 - February 2022 we undertook an audit of all of our existing beds against the 
children’s bed standard, BS EN 50637:2017, which came into force in August 2020 for beds sold after 
that date.  Although the standard does not apply retrospectively to beds already in use, we took the 
opportunity following our audit to replace twenty junior beds, eight adult beds and three cots.  We 
introduced two new bed models conforming to BS EN 50637:2017; the ‘Linet Tom 2 Cot’ and ‘Accora 

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

Floorbed’. The new beds have built in cot sides and padding, integral to the bed rather than separate 
bumpers. 

Servicing and maintenance, governance and record keeping 
We  have  contracts  in  place  with  two  UK-based,  bio-medical  engineering  repair  and  maintenance 
companies who carry out regular inspections of medical equipment and devices and undertake repairs 
and preventive maintenance.  Our estates compliance team monitors a number of KPIs on a monthly 
basis  to  provide  assurance  that  beds  and  other  clinical  assets  have  been  serviced  in  line  with  the 
relevant servicing schedule.  Compliance has averaged 99% over the last quarter.     

We acknowledge that our record-keeping around the servicing of beds at the time of Connor’s death 
was  not  robust.    However,  as  detailed  in  the  learning  statement  presented  by  our  current  medical 
director at the inquest and in this report, in the last five years we have made significant improvements.   

We commissioned Croydon Healthcare Services to undertake an external review of all our clinical assets 
inventory and service and maintenance data in January 2019 and entered into a  medical equipment 
maintenance service level agreement with Croydon Healthcare Services in February 2019.  Around the 
same  time,  we  established  a  new,  clinical  assets  working  party  meeting,  chaired  by  the  director  of 
clinical services, with responsibility for developing and monitoring effective governance arrangements, 
policies and procedures for the safe deployment of all medical devices.  In May 2020 we appointed a 
dedicated clinical assets lead, responsible for maintaining the clinical assets register and coordinating 
and  overseeing  servicing  and  maintenance  in  line  with  statutory  requirements  and  manufacturers’ 
guidance. 

In October 2020, we transferred our Excel-based clinical assets register and maintenance records to a 
new centralised system, “CATi”. As part of this project, we completed a “desk-top bed audit” followed 
by a physical inspection and a validation of service history data. A bed condition report was completed 
and reviewed by the Clinical Governance & Safeguarding Committee. 

Our Internal Audit team completed a “Clinical Assets Lifecycle Management” audit in September 2021 
which found there to be good processes and controls in place around the tagging, recording, servicing 
and maintenance of beds and other medical equipment. The report made a few recommendations to 
further improve controls, including more centralised record keeping around training and a more robust 
process for staying up to date with changes in regulations and standards in relation to medical devices.   
The  implementation  of  management  actions  from  internal  audits  is  monitored  by  our  Audit  &  Risk 
Committee. 

Policies, procedures, training and guidance for staff 
As  detailed  in  the  evidence  of  our  current  medical  director  at  the  inquest,  as  part  of  the  learning 
following Connor’s death, we have updated our Medical Devices and Equipment Policy and keep this 
under review to ensure it is aligned with current regulations and best practice.  

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

Specialist equipment such as adapted beds, sleep systems, moving and handling devices and seating 
must be risk assessed by a qualified registered professional before use.  

Staff are trained in the appropriate use of clinical assets in a number of ways including through our 
existing clinical competencies assessments and moving and handling training programmes; as part of 
“therapy training days” and “in practice learning”.  Nursing and care staff are also required to familiarise 
themselves with individual care plans which contain guidance, including photographs, on the use of 
specific clinical assets assigned to each child or young person. 

When new equipment is purchased or introduced, the clinical asset lead and clinical education team 
will check whether training is adequately covered by existing programmes. If it is felt that additional 
training  is  needed,  the  clinical  asset  lead  will  arrange  for  a  representative  of  the  manufacturer  to 
provide training either directly to nursing and care staff and therapists or on a “train the trainer” basis.  

It is mandatory for nursing and care staff to carry out and to document checks on beds, cots, bumpers 
and other equipment twice in every 24-hour period, once during the day shift and once during the night 
shift.    Compliance  is  monitored  through  quarterly  audits.  For  the  quarter  ending  January  2022, 
compliance was assessed as 98.8% (and 98.1% for the previous quarter).  

Should equipment be identified as faulty, staff are required to report it immediately to the facilities 
helpdesk using our “Top Desk” reporting system, accessible via our intranet. The equipment in question 
will immediately be taken out of service for repair or replacement. Larger items will be clearly tagged 
to state they are “out of use” and moved out of the child or young person’s room, as applicable.  

Concern 
1.2  Monitoring of Connor during the night  

“Connor had no regular or direct visual supervision during the night (other than to open the door of his 
room to check if there was a smell) despite the request of his foster parent to check in circumstances 
whereby in other parts of the Trust regular visual inspection was the norm.”  

Response  

Overnight monitoring policy 
As detailed in the evidence of our medical director at the inquest, following Connor’s death, our sleep 
monitoring procedures were reviewed and revised immediately, to ensure the safety and wellbeing of 
the children in our care during sleep.  

In  accordance  with  our  current  Sleep  Monitoring  Policy,  a  mandatory  risk  assessment  is  completed 
when each child or young person is first admitted to our service and is reviewed and updated regularly 
to  reflect  changing  needs.  The  risk  assessment  is  completed  by  a  qualified  nurse  and  identifies  the 
nature, frequency and extent of monitoring required when a child is sleeping, in consultation with their 

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

allocated doctor. In assessing the risk to each child, nurses and doctors will take into account clinical 
presentation, for example a child may be more susceptible to sudden death following an acquired brain 
injury if they have co-morbidities. Where a child or young person is assessed as being at greater risk, 
for  example,  if  they  experience  seizures  and  apnoea  or  have  respiratory  conditions  requiring  the 
administration of oxygen, monitoring would be more frequent and would include measures beyond 
visual surveillance such as monitoring heart rate and oxygen saturation levels.  

Our clinical protocols and guidelines outline when to initiate continuous vital signs monitoring, should 
there  be  a  deterioration  in  clinical  presentation  and  set  out  other  escalation  practices  such  as 
administering oxygen, changing the settings on a ventilator, or calling for an ambulance.  The care plan, 
which is informed by the risk assessment, is written in collaboration with the parents/ carers of the 
child, who must also sign it to show their agreement with its provisions.  

Our  current  Sleep Monitoring  Policy  is  due  for  review  in  July  2022,  in  line  with  our  standard  policy 
review cycle. Two changes we will be making to the policy will be to expand its scope and to rename it 
the ‘Frequency of Monitoring Policy and Procedure.’  These changes will ensure that we incorporate 
the required monitoring practice over a 24-hour period and not just whilst a child or young person is 
asleep overnight. 

Visual Surveillance 
As outlined in the Sleep Monitoring Policy, the minimum required level of visual surveillance includes 
entering  the  bedroom  and  physically  observing  and  assessing  a  child  to  ensure  they  are  sleeping 
soundly, are not tangled in any bedding, are comfortable and not in distress. If a parent or carer would 
prefer that a medically stable child should not be disturbed overnight then this is risk assessed and, as 
a  minimum,  an  audio-visual  monitor  would  be  used to  allow  remote  observation.  The  frequency  of 
monitoring  overnight  is  clearly  documented  in  every  child’s  care  plan  and  must  be  signed  by  the 
parent/carer and a registered nurse. 

Reviewing and agreeing the care plan with families/ carers 
We have reviewed our process for developing and agreeing each child’s care plan, including sleeping 
arrangements and overnight monitoring. Whilst we will always consider the wishes of families, we must 
always use our professional skill and judgement, informed by a child/ young person risk assessment, to 
determine what we believe to be in his/ her best interests. Our Sleep Monitoring Policy clearly states 
the minimum standards for surveillance. We have recently benchmarked our sleep monitoring practice 
at The Children’s Trust against that of similar organisations and have found it to be more robust, both 
in terms of the frequency and nature of checks undertaken.  

Record keeping 
We acknowledge that at the time of Connor’s death, we did not have robust record-keeping in place to 
evidence  overnight  monitoring  checks.  We  have  addressed  this  by  introducing  a  24-hour  sleep 
monitoring  chart  that  must  be  completed  for  each  child  every  day.  The  chart  documents  the  time 

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

periods during which a child is awake and asleep (day and night), when visual surveillance checks are 
performed and the exact positioning of a child or young person in their cot/bed. The chart is part of a 
large A3 Nursing and Care 24-hour evaluation document.  It must be countersigned by the shift lead or 
a registered nurse. A laminated guide for completing the 24-hour evaluation chart which incorporates 
sleep monitoring and equipment safety checks is displayed at the nurses’ station on each house. 

Compliance monitoring 
Compliance with the Sleep Monitoring Policy is assessed through quarterly audits by nursing and care 
staff of a selection of clinical records. The audits look for evidence of i) risk assessments having been 
completed appropriately, ii) control measures identified to manage the risks having been incorporated 
into the care plan and iii) those control measures having been adhered to and documented in the 24-
hour  evaluation  chart.  The  most  recent  audits  in  September  2021  and  January  2022,  respectively 
reported 99.4% and 98.1% compliance, respectively. 

2.0 

Other Concerns Raised by the Coroner    

Concern 
2.1 Probity and Investigation by the Children’s Trust, Tadworth  

“The police and the coroner’s service attending the Trust shortly after being informed of Connor’s death 
were not fully informed of the circumstances of his death. The scene had not been preserved. They 
were not told of the position Connor was found, that he had been dead for some time (likely hours) or 
that the padded board was initially found across his neck and that it required force by either one or two 
nurses for it to be pushed down to be removed.  

Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and 
medical director) were concerned at the time the role the padded board may have played in Connor’s 
death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their 
own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, 
they arguably misled the CQC as to the circumstances of Connor’s death. Likewise, the pathologist who 
undertook  the  autopsy  on  Connor  was  not  informed  of  the  circumstances  of  his  death  thereby 
preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have 
played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without 
fully  informing  him  of  the  position  the  cot  bumper  may  have  played  in  Connor’s  death.  The  Trust 
undertook several Serious Investigation reports, the first of which was six months after Connor’s death. 
These reports did not acknowledge or address the role the cot bumper may have played in Connor’s 
death despite evidence from multiple witnesses indicating it was likely to be significant.” 

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

Response  

Information provided to the police and coroner’s service 
We  willingly  complied  with  all  external  investigations  that  took  place  and  also  carried  out  our  own 
detailed review.  The evidence before the coroner at the inquest was that the police officer attending 
the scene following Connor’s death had been informed of the position in which the cot bumper had 
been found. This was reflected in the contemporaneous notes taken by the officer in their police-issued 
pocket notebook. The officer in question gave evidence at the inquest that he had been informed of 
the positioning of the bumper.   

Connor’s tragic death has been the only unexpected death in our organisation’s 38-year history. At the 
time, staff were unfamiliar with the correct procedure to follow and allowed the coroner’s officer to 
take Connor’s medical records with them without making a copy. It was our understanding that a copy 
of Connor’s medical records which included notes on the exact position in which the cot bumper had 
been found and subsequent events was to be provided, by the Coroner’s Office, to the pathologist who 
undertook the autopsy on Connor. These records as well as a copy of the transcribed recording of the 
adjourned inquest in April 2018 were also provided to the forensic pathologist that we instructed to 
provide an expert opinion and to assist the court. Copies of the letters of instruction sent to the forensic 
pathologist were provided to the coroner.  The medical records handed over to the coroner’s officer 
included the “Nursing 24-hour Continuous Evaluation” which states the following in the entries on the 
morning of Connor’s death, at 08:40 and 09:05 respectively: “Child was seen with head down to his 
chest and a cot bumper against the chest area.”  and “…together we opened the cot side and removed 
cot bumper which was under his neck”.   

In terms of the assertion that we did not communicate the time of death to the police or Coroner’s 
Office, the pathologist’s post-mortem report states on page two of eight, under the heading “clinical 
history”, “..he appeared to have been dead for some time and therefore no CPR was attempted”.  The 
witness  statement  submitted  by  the  former  medical  director  and  provided  to  the  coroner’s  service 
stated; “Appearances were consistent with death having occurred at least one or two hours earlier.” 
and the  police  notes  also state “Dr Morgan stated that  Connor  had been deceased for  well over an 
hour”.   

However, we accept that we could have more explicitly highlighted the potential role of the cot bumper 
by preparing a report of initial findings to be made available to the pathologist, Coroner’s Office and 
police.    We  should  also  have  provided  more  detail  about  the  circumstances  of  Connor’s  death,  in 
particular the position he was found in relative to the cot bumper, to the consultant paediatrician at 
Sheffield Children’s Hospital, who conducted the child death review.  

Failure to preserve the scene 
Our nursing and care staff are taught to urgently undertake a clinical assessment of any child or young 
person who they discover in an unresponsive or deteriorating medical state.  We train staff in basic life 
support (BLS) in line with the Resuscitation Council UK’s national guidelines, 2021; to assess a patient’s 

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

airway,  check  for  breathing,  and  check  circulation.    Accordingly,  when  our  staff  first  found  Connor 
unresponsive in his cot, they moved him into a horizontal, supine position in order to assess his vital 
signs.    The  police  then  performed  their  own  independent  physical  examination.  All  of  Connor’s 
equipment remained in the room with him, and the room (including the bed and bumpers) remained 
sealed until the findings of the post-mortem were released. 

Our Basic Life Support (BLS) training follows the Resuscitation Council UK guidelines and is mandatory 
for all nursing and care staff. Shift leaders and senior nurses also attend an enhanced BLS+ training 
annually  which  is  designed  to  increase  knowledge,  skills  and  confidence  in  managing  medical 
emergencies. It further emphasises and builds upon the Resuscitation Council UK guidelines taught in 
BLS  and  includes  enhanced  simulations  and  training  around  escalation  of  care  and  management  of 
medical emergencies more relevant to our service. Additionally, the training covers how to call for help, 
using the bleep system, using call bells, dialling 999 and at what point each might be appropriate. Each 
BLS session ends with a mandatory assessment of skills.   

At the inquest, the coroner heard evidence that in order to ensure all staff members are aware of the 
necessary actions to take in the event of an unexpected death, we have incorporated additional content 
into  the  mandatory  basic  life  support  training  that  all  staff  must  receive  on  induction  as  well  as  a 
mandatory annual update.   

In  addition  to  this,  we  have  reviewed  The  Royal  College  of  Pathologists  guidelines  on  ‘Sudden 
unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation,’ 2016, 
and guidance  produced by the  Surrey Child Death Review Partnership. We are further developing a 
clear protocol and training for our nursing and medical staff in the event of an unexpected child death. 
We accept that our training has historically focussed on basic life support and actively assessing and 
supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to 
receive their basic life support training, we will have clear guidelines on processes and actions to be 
taken  in  the  event  of  a  sudden  unexpected  death.  We  are  also  planning  to  expand  our  existing 
simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.  

Record keeping 
All of Connor’s (original) medical records were sent on 17th May 2017 with the coroner’s assistant to 
inform the post-mortem.  We omitted to make copies of these notes and they were not returned until 
after  the  post-mortem was  completed, six months  later.  It  was  not  until  this  time  that our  internal 
investigation  could  commence.  We  acknowledge  that  it  was  a  mistake  not  to  make  copies  of  the 
medical notes.   

Our internal investigation 
Regrettably,  and  as  detailed  in  evidence  at  the  inquest,  we  were  unable  to  undertake  an  internal 
investigation  until  the  medical  records  had  been  returned  from  the  Coroner’s  Office.  They  were 
returned  on  28th  November  2017,  over  six  months  later.    Our  initial  internal  investigation  did  not 
examine the issue of the cot bumper as we had been informed by the Coroner’s Office that the post-

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

mortem investigation had concluded that the cause of Connor’s death  was  undetermined but  most 
likely to have been natural causes.   

We accept that we should have thoroughly examined the potential role of the cot bumper in our initial 
investigation.   With hindsight we were too quick to rule the bumper out based on the post-mortem 
findings.  Our learnings here are reflected in the updates we have since made to our “Incident Reporting 
and Investigation, including Duty of Candour Policy”.  

Notification to statutory bodies 
At  the  time  of  Connor’s  death,  The  Care  Quality  Commission  (CQC)  was  the  only  regulator  of  the 
rehabilitation services Connor was receiving at The Children’s Trust.  More recently, our entire site at 
Tadworth Court has been designated a “children’s home” bringing our rehabilitation service in scope 
of the Children’s Homes Regulations as well, which are regulated by Ofsted.   

Our  former  head  of  nursing  and  care  formally  notified  the  CQC  of  Connor’s  death  via  their  online 
statutory notification system on the 17th May 2017, the day of Connor’s death. The notification clearly 
stated the  position he  was found in, the position of the cot  bumper ‘across his chest  area’ and the 
emergency “ABC” assessment performed. In this notification we did incorrectly advise that Connor had 
been checked every 15 minutes overnight.    However, once the medical notes were returned from the 
Coroner’s Office in November 2017 and we could begin our investigation, we realised our error.  We 
contacted the CQC on 29th November 2017 explaining the sleep monitoring arrangements that had in 
fact been in place for Connor.  The CQC has confirmed they have a record of this call and have provided 
us with the transcript.   

We accept that, had we made a copy of Connor’s clinical notes prior to them leaving our site with the 
coroner’s officer, we would have had more factual information to provide within our CQC notification 
on the day of his death. This learning is reflected in our protocol we are developing in line with the 
Royal  College  of  Pathologists  guidance:  ‘Sudden  unexpected  death  in  infancy  and  childhood:  Multi-
agency guidelines for care and investigation’ and current statutory guidance. 

Connor was commissioned for a placement at The Children's Trust but resided permanently in Sheffield. 
Following his death, notification was made to his local teams, and the former medical director at The 
Children's Trust provided information to the consultant paediatrician at Sheffield Children’s Hospital, 
who  conducted  a  child  death  review  and  produced  a  formal  report,  dated  25th  May  2017.  On  16th 
November 2017 a ‘multi-agency case discussion following unexpected child death’ was held in Sheffield, 
chaired by the designated doctor for child deaths.   

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

Concern 
2.2  Senior Management, The Children’s Trust, Tadworth  

“The current senior management team have not acknowledged there was a lack of transparency and 
openness as to how Connor died, or that the Trust did not properly investigate his death or inform the 
relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of 
insight that institutional learning around serious incidents has not been accepted by the Trust.  

As a consequence, there is a need to introduce and develop robust clinical governance processes and 
systems to reassure the public and supervisory statutory bodies that they will be informed of any future 
adverse events and they will be investigated with openness, candour and transparency.” 

Response 

We are, of course, saddened by the coroner’s finding that we were said to have lacked transparency 
and  openness  around  Connor’s  death.    However,  we  are  also  an  organisation  that  is  committed  to 
listening and responding to all feedback, even when it is difficult to hear.  

We accept the coroner’s finding that we did not properly investigate the circumstances of Connor’s 
death and that we could have highlighted the potential role of the cot bumper more explicitly to the 
pathologist via the Coroner’s Office.  However, these oversights were as a result of a lack of experience 
in  responding  to  and  investigating  an  unexpected  child  death,  rather  than  from  any  intention  to 
mislead.  

The coroner heard evidence from the former director of clinical services, the former medical director 
and the current medical director.  The evidence of our current medical director intended to provide the 
court  with  further  information  in  respect  of  the  changes  implemented  following  our  internal 
investigations and wider learning across The Children’s Trust. 

Both  our  current  medical director  and  the  former  director clinical  services  offered  their  unreserved 
apologies  to  the  family  in  respect  of  Connor’s  tragic  death  and  the  conduct  of  our  subsequent 
investigations.   

Our  senior  leadership  team,  with  the  full  involvement  of  our  board  of  trustees,  has  established  a 
learning action group (overseen by our Clinical Governance & Safeguarding Committee) dedicated to 
developing new processes and systems that will address the coroner’s concerns and will build upon the 
improvements we have been making over the last five years.   

We want to reassure Connor’s family, and others, that we will do everything we can to ensure that 
something like this cannot happen again. 

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Tadworth Court 
Tadworth  
Surrey KT20 5RU 

thechildrenstrustorg.uk 

We hope that we have provided you with robust assurance that we have already taken steps to address 
the issues of concern in your report and that we are continuing to take action to strengthen the quality 
and safety of care we provide to children and young people. 

Signed on behalf of the senior leadership team and board of trustees of The Children’s Trust: 

____________________________________________ 
Dalton Leong 
Chief Executive 

___________________________________________________ 
Duncan Ingram 
Chair of Trustees

The Children’s Trust is accredited by CHKS with ISO 9001 certification  
(for organisational and clinical management systems), inspected  
and rated ‘Outstanding’ by Care Quality Commission and rated  
a ‘Good Provider’ by Ofsted Care (for residential houses).  
Registered charity number: 288018. A company limited by guarantee;  
registered in England and Wales with registered number 1757875.