Mia Gauci-Lamport

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 
Fax: 03000 616171 

www.cqc.org.uk 

HM Coroner Karen Henderson 
HM Coroner's Court, Station Approach,  
Woking,  
Surrey,  
GU22 7AP 

By Email 

05/12/2024 

Care Quality Commission 

Dear HM Coroner Karen Henderson 

CQC  response  to  prevention  of  future  death  report  Mia  Louise  Guaci-
Lamport  

Thank you for naming the Care Quality Commission (CQC) as a respondent in the 
prevention of future death report issued on 20/10/2024 following the death of Mia 
Louise Guaci-Lamport. 
We would like to extend our sincere condolences to Mia’s family.  

The Children's Trust – Tadworth provides a residential children's home for 
children and young people with profound and multiple learning disabilities, a 
residential rehabilitation service for children and young people with acquired 
brain injury and a short breaks service. Ofsted are the lead regulator for The 
Children's Trust because of its status as a children’s home. The service is also 
registered with the Care Quality Commission but only for the regulated activity of 
treatment of disease, disorder, or injury. Therefore, the CQCs remit extends to 
regulation of this regulated activity only. CQC does however work closely with 
Ofsted as partner regulator. 

We note that the concerns are as follows: 

1.  Lack of appropriate monitoring of Mia during the night:  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mia’s  underlying  illness  caused  seizures  which  were  multifocal, 
complex  and  variable  from  tonic-clonic,  myoclonic  to  cluster  and 
absence seizures. Her care plan stipulated that carers should enter her 
room every 15 minutes to undertake visual observations  throughout 
the night to ensure Mia was in a safe position, was breathing and not 
at risk of asphyxiation. However, this did not take place as frequently 
as specified. Moreover, it was common practice amongst some carers 
to  review  images  from  a  video  monitor  placed  over  Mia’s  cot  rather 
than direct visualisation despite it being recognised that the monitor 
was  insufficiently  sensitive  to  reassure  the  carer  that  Mia  was 
breathing, seizure free and safe from asphyxiation 

On  11th  September  2023  we  received  a  notification  from  the  registered 
manager  at  The  Children’s  Trust  (TCT)  regarding  Mia’s  death  where  we 
immediately requested a copy of  TCT’s initial investigation and the outcome 
of the police report. The police report stated that Mia’s death was not being 
treated as a criminal investigation. We liaised closely with Ofsted, who also 
inspect and regulate accommodation, care and education at  TCT. We were 
aware  that  they  had  scheduled  an  inspection  imminently.  Taking  into 
consideration these factors, we made the decision to wait until the outcome 
of  Ofsted’s  inspection  was  known  and  could  be  considered  alongside 
findings from TCT’s own external investigation before a CQC inspection.  

Ofsted inspected  TCT in September 2023 and rated them good in all areas. 
They issued one requirement  of “Individual care plans must be explicit in 
relation to the levels of staff supervision required to meet children’s needs. 
Where this includes the use of visual monitoring, this needs to be included 
in  children’s individual  plans.  Ensure that these plans  are accessible and 
understood by all staff.”  

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. 

On 12th December 2023 CQC requested an update regarding the progress 
of the external investigation. TCT leadership team notified CQC they were 
not happy with the standard of the first external investigation report due to 
it not being sufficiently comprehensive and that they had commissioned a 
second  external  investigation.  A  comprehensive  CQC  inspection  was 
scheduled for February 2024. 

2 

 
 
 
 
 
 
 
 
 
 
 TCT  continued  to  update  CQC  on  the  progress  of  the  second  external 
review.  On  11th  January  2024  we  received  an  email  from  the  registered 
manager  at  TCT  to  inform  us  they  had  now  commissioned  the  second 
external review and terms of reference had been agreed.  

In December 2023 CQC had received key information and started to plan 
for  an  inspection  in  February.  On  February  20th  to  21st  2024  the  CQC 
undertook  a  comprehensive  inspection  of  TCT  as  part  of  our  regulatory 
response to the notification of Mia’s sad death. The inspection looked at all 
five key questions of whether TCT is Safe, Effective, Caring, Responsive 
and Well-led. (Please see attached PDF). CQC do not provide ratings for 
children’s homes that are registered with Ofsted, as per our policy.  

During the inspection we reviewed a selection of audits and 18 children’s 
records,  and  we  did  not  find  any  evidence  of  care  deviating  from  that 
stipulated in the care plans. However, when speaking with staff we found a 
variance in their understanding of how visual checks should be undertaken. 
Therefore,  we  recommended  that  TCT  should  strengthen  the  detail  of 
description of one to one care and observations related to overnight care 
within  children  and  young  people's  care plans.  TCT leaders informed  the 
CQC  that  processes  were  immediately  implemented  to  ensure  all  house 
managers were assured staff understood what actions were required during 
a visual check and children’s care plans were updated accordingly.  

CQC  assumed  enforcement  responsibility  for  health  and  safety  related 
serious incidents concerning people using services in health and social care 
settings in England in April 2015. This is where people using services (SUs) 
have sustained avoidable harm including death, have been exposed to a 
significant  risk  of  avoidable  harm,  or  have  suffered  a  loss  of  money  or 
property as a result of a failure by the Registered Person. The ‘Registered 
Person’  (RP)  is  the  Registered  Provider and/or  Registered  Manager.  We 
used the CQC specific incident guidance to make a decision about:  
1.  Does  the  information  about  the  specific  incident  raise  concerns  about 
ongoing risk of harm to users of the service which CQC should inspect?  
2.  Does  the  information  about  the  specific  incident  suggest  the  harm 
sustained  was  avoidable  and  may  have  resulted  from  a  breach  of  a 
prosecutable fundamental standard? 

When we received each new piece of information regarding Mia’s case, we 
reviewed  this  against  our  specific  incident  guidance  and  concluded  that 
there was not a breach of prosecutable fundamental standard.  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 In  July  2024  following  the  coroner’s  inquest  and  information  from  the 
independent investigator report, CQC requested monthly updates from TCT 
regarding  the  providers  audits  of  frequency  of  monitoring  of  children  and 
their  Paediatric  Early  Warning  System  (PEWS).  The  audits  and  actions 
taken,  provided CQC with assurance the leadership team continued to take  
positive action to address any gaps in practice that the audits identified.  

2.  Medical Care provided to Mia:  

Mia’s medical records at TCT were neither comprehensive nor easy to 
understand  and  did  not  conform  to  the  expected  standard  in  NHS 
general or hospital practice to ensure accurate and contemporaneous 
medical care was being reviewed and documented. Mia was a ‘looked 
after’ child with complex and challenging health needs and could not 
contribute or make decisions for herself. The independent investigator 
found regular PEWS (Paediatric Early Warning Scores) assessments 
were not undertaken to ensure Mia’s wellbeing despite it being within 
her  care  plan.  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 was reviewed 
by  a 
‘privately-funded’  consultant  employed  by  but  working 
independently  of  Great  Ormond  Street  Children’s  Hospital  as  and 
when  requested  by  the  medical  staff  at TCT.  The  consultant  had  no 
terms  of  reference  and 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 
not available from April to October 2023. In this context, Mia was not 
under  a  specialist  NHS  paediatric  neuro-consultant  to  ensure  her 
ongoing medical needs conformed to expected practice nationally and 
for  an  independent  consultant  outside  of  TCT  to  have  regular 
oversight  and  co-ordinate  investigations  and  any  further  multi-
disciplinary  management  she  may  need  given  this  progressive  life-
limiting condition. 

During  the  20th  –  21st  February  2024  inspection  the  CQC  reviewed  18 
PEWS charts and found these had been fully documented with the correct 
escalation  if  the  PEWS  scores  were  escalating.  We  found:  “evidence  in 
children  and  young  people's  records  that  staff  assessed,  monitored,  and 
managed  risks  well.  Care  plans  we  reviewed,  were  comprehensive  and 
covered all aspects of the child and young person's life such as moving and 
handling,  sleeping  positions,  medicines,  and  specific  conditions  such  as 
epilepsy management”. Please see attached inspection report. 

4 

 
 
 
 
 
 
 
 
 
 We have since received three months’ worth of PEWS audits which shows 
a  95-97%  compliance  rate  with  evidence  of  learning  and  improvements 
where required.  

As per 
’s witness statement it is our understanding that Mia was 
not without specialist NHS paediatric neuro-consultant care at any time as 
the paediatric neurology department at St George's Hospital (SGH), Tooting 
is the tertiary centre for paediatric neurology in the region. There is a shared 
care arrangement between the neurology department and the SGH and the 
paediatric department at Epsom hospital, therefore if Mia had required any 
specialist  neurological  care  this  would  have  been  provided  by  Epsom 
hospital. 

Prior to the inspection our review of evidence did not identify any deficits in 
care regarding children having ‘privately funded consultants’, therefore this 
was not an active line of enquiry. However, with regards to regular oversight 
and  co-ordination  of  investigations  we  found  during  the  February  2024 
inspection that “the medical team have monthly complex case discussions. 
This is an opportunity for the full multidisciplinary team to learn from each 
other  and  reflect  on  cases  that  have  gone  well  and  identify  areas  for 
improvement”.  We  found  all  children  were  able  to  access  NHS  services 
either  through  their  local  NHS  hospital  or  the  tertiary  centre  they  were 
receiving treatment from. The February 2024 report noted “The doctors at 
the Children's Trust attended transition planning meetings and advocated 
for tertiary and GP care. They oversaw the transition planning and referred 
to specialist clinics as required”.  

Following the Coroner’s inquest, we requested an update regarding TCT’s 
governance  arrangements  around  independently  practicing  consultants. 
TCT  told  us  that  all  the  consultants  they  were  currently  using  all  had 
substantive  posts  within  an  NHS  trust,  but  that  they  were  reviewing  their 
governance  processes  regarding  if  a  clinician  did  not  have  a  substantive 
post within an NHS trust.  

3.  Senior management, Children’s Trust, Tadworth:  

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. 
The  Independent  investigator  commissioned  by  TCT  highlighted 
initial 
ongoing  clinical  governance 
management  and  investigation  of  Mia’s  death,  delay  in  fulfilling  the 
Duty of Candour’ obligations, ongoing staff training, ensuring robust 

limitations 

including 

the 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 procedures were in place alongside regular audits of clinical practice. 
These  are  the  same  issues  highlighted  in  the  PFD  report  I  issued 
touching on the death of Connor Wellsted two years previously. 

Since the sad death of Connor Wellsted in 2022 and Mia’s death, CQC have 
undertaken  three  subsequent  inspections  which  have  demonstrated  that 
TCT  have  taken  the  appropriate  actions  to  ensure  the  governance 
processes around night time observations have been strengthened.  CQC 
is assured with regard to it’s own regulatory functions, by the actions taken 
by  TCT.  Specifically  this  includes  to  strengthening  the  frequency  of 
monitoring policy  and increased  their  audits of  the  implementation of  this 
policy. 

During  the  February  2024  inspection  we  found  all  staff  had  received  the 
appropriate level of training relevant to their role and the healthcare activity 
they deliver.The education team provided child and young person specific 
training as the need arose.  
We also noted that “staff demonstrated knowledge of the Duty of Candour, 
to be open and transparent with people including when things go wrong with 
their care and treatment”. In Mia’s case there was a delay in executing the 
Duty  of  Candour,  however  the  CQC  did  not  deem  this  instance  to  be  a 
breach of Health and Social Care Regulations.  

CQC have seen evidence of a strengthened learning culture at  TCT through 
inspection and routine engagement conversations. We have seen progress 
in their action plan against the recommendations made by CQC from both 
the  January  2020,  May  2021  and  February  2024  inspections  and  the 
external investigation of Mia’s death. In addition TCT  had a Frequency of 
Monitoring Policy in place since July 2022 which continues to be reviewed 
and updated. TCT have taken appropriate action to ensure they are not in 
breach of Regulation 12 safe care and treatment.  

The senior leadership team at TCT continue to be receptive and responsive 
to challenge and proactive in providing information to CQC to demonstrate 
how improvements have been made in response to incidents, complaints 
and inspection findings.  

The  CQC  will  continue  to  work  closely  alongside  Ofsted  to  monitor  and 
inspect  according  to  our  current  inspection  methodology  and  continue  to 
respond  to  any  emerging  risk  identified  through  monthly  data  assurance 
reports,  regular  engagement  meetings,  notifications  or  whistleblowing 
reports.  

6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

7

Parliamentary Under-Secretary of State for   
Patient Safety, Women’s Health and Mental Health 

39 Victoria Street  
London  
SW1H 0EU  

16 December 2024 

Our ref: 

HM Coroner Dr Karen Anderson 
HM Coroner’s Court 
Station Approach 
Woking  
GU22 7AP 

By email: 

Dear Dr Henderson,  

Thank you for the Regulation 28 report of 14 October sent to the Secretary of State about 
the death of Mia Louise Gauci-Lamport. I am replying as the Minister with responsibility for 
Patient Safety.       

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

The report raises concerns around the:   

1.  lack of appropriate monitoring of Mia during the night; 
2.  medical care provided to Mia and; 
3.  senior management at The Children’s Trust (TCT), Tadworth. 

In preparing this response, my officials have made enquiries with NHS England (NHSE) and 
the Care Quality Commission (CQC) to ensure we adequately address your concerns.  

I deeply sympathise with the family and your concerns, which as you state in the report were 
also  raised  two  years ago.  It  is  important  to  understand  what  occurred  to  fully  grasp  the 
reasons for this unfortunate death, and what measures will be put in place to stop it from 
happening again. We have sought assurances from  CQC and NHSE, who further sought 
assurance from TCT, that responses are being prepared to address concerns respective to 
each organisation. 

In parallel, 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 Mia’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. 

NHSE have informed us that their regional specialised service team commissioned some 
beds at TCT for specialised rehabilitation for those with complex needs, but it appears that 

 
   
 
 
 
 
 
 
  
  
  
 
 
 Mia was in a residential care bed, which is  commissioned instead by the Local Authority. 
The  commissioning  body,  in  this  case  the  LA,  has  the  responsibility  for  oversight  of  the 
quality  of  the  service. 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. In case of interest, NHSE’s 
guidance  on  specialised  services  can  be  found  here:  NHS  commissioning  »  Specialised 
services.  

In relation to your point about the delay in fulfilling the duty of candour obligations, as you 
may be aware, the statutory duty of candour (organisational) places a direct obligation upon 
NHS trusts and all other health and social care providers registered with the CQC to be open 
and honest with patients, service users and their families, when a notifiable safety incident 
occurs. 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. The Department’s aim is to ensure the NHS can better meet the 
objectives of the statutory duty of candour and work with patients as partners to support a 
culture of learning and continuous improvement. 

Patient  Safety  is  of  utmost  importance  for  this  government  across  all  services.  I  strongly 
believe that lessons learnt must be implemented robustly to change the way patient safety 
is approached in healthcare, and that they are enduring. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR 
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH

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

Dear Coroner, 

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

09 December 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Mia Louise Gauci-
Lamport who died on 11 September 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  14 
October 2024 concerning the death of Mia Louise Gauci-Lamport on 11 September 
2023. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Mia’s family and loved ones. NHS England 
are keen to assure the family and the coroner that the concerns raised about Mia’s 
care have been listened to and reflected upon.   

Your Report raises multiple concerns in relation to the medical care and appropriate 
monitoring of Mia, including concerns regarding the access to clinical consultant care 
and a lack of adherence to her care plan within the residential care setting at Tadworth 
Children’s Trust (TCT).  Noting you have also sent your Report to TCT and CQC, some 
of  the  concerns  you  raise  may  be  better  addressed  by  those  organisations.  In  this 
response, I have addressed the matters of concern where NHS England are able to 
contribute and provide some assurance. 

My  response  to  your  Report  has  been  informed  by  colleagues  in  the  South  East 
Region Direct Specialised Commissioning Quality team who commission 12 beds from 
Tadworth  Children’s  Trust  (TCT)  on  behalf  of  NHS  England  for  specialised 
rehabilitation  for  patients  with  complex  needs.  However,  I  should  like  to  clarify  that 
Tadworth Children’s Trust is also commissioned for other levels of rehabilitation and 
residential care funded by Integrated Care Boards (ICBs) and local authorities.  TCT 
have  a  total  provision  for  up to  50  children.  Whilst  you  have  drawn  our  attention  to 
previous concerns you have raised about TCT in an PFD report following the death of 
Connor Wellsted, TCT have confirmed that Mia was within its residential care provision 
commissioned by the local authority and was not in a specialised commissioning bed 
for which NHS England would have had oversight. 

Even though NHS England had no direct or commissioning oversight of Mia’s care, I 
should  like  to  provide  you  and  Mia’s  family  with  some  assurance  that  our  regional 
Specialised  Commissioning  team  has  been  working  with  TCT,  alongside  other 
stakeholders, to review the quality of care being provided.  This has taken the form of 
Rapid Quality Review (RQR) meetings in accordance with the National Quality Boards 
guidance on risk response and escalation in ICSs where concerns are raised about a 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 provider.  This  multi-stakeholder  meeting  gives  specific,  focused  consideration  to 
quality concerns or risks raised, helps to facilitate rapid diagnostic work and looks to 
formulate an agreed action and improvement plan with the provider. Such meetings 
bring  together  regional  safeguarding,  quality,  local  authority,  acute  trust,  CQC  and 
clinical and governance teams. 

A recent RQR meeting with TCT has resulted in an agreed plan for them to adopt the 
national paediatric early warning system (PEWS). This is a standardised approach for 
tracking  the  deterioration  of  children  used  in  hospital  settings.    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.  In 
addition,  the  nursing  colleagues  have  offered  to  support  TCT  with  training  and 
education of staff and to act as a critical friend to improve nursing and carer practice 
on appropriate observation and monitoring. The PEWS system also has standardised 
charts for recording clinical information and observations which will also help improve 
consistency of medical record keeping at TCT.   

In terms of multi-disciplinary and collaborative care provision, at the RQR meeting, it 
was agreed that TCT would ensure children were only accepted when the correct care 
had been commissioned and that the right level of care could be safely provided.  

Whilst  a  RQR  meeting  helps  support  and  implement  plans  for  a  provider  following 
identification of a risk or concern, it also gives the provider a platform to raise concerns 
or challenges they have in being able to deliver that care.  At the RQR meeting with 
TCT, it was acknowledged that they not been able to consistently engage with NHS 
partners to support their care pathways for each child in their care. Although the clinical 
teams at TCT have worked hard to form connections with primary care and clinical 
teams within the NHS, it is acknowledged that agreed pathways are not always easy 
to  progress  with  those  teams.  To  help  bridge  that  relationship  and  ensure  better 
consistency of collaborative care, TCT agreed to further their connections within the 
local integrated care system and with tertiary care providers to improve flow to clinical 
appointments.  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.   However,  it  would  remain  TCT’s 
responsibility to ensure consistency of multi-disciplinary clinical support for all children 
in their care, whether accessed via NHS or privately funded. 

I would also like to provide further assurances on national NHS England 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 Mia, 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

Regulation 28:  Report to Prevent Future Deaths, Mia Gauci-Lamport  

Coroner’s Concerns 

The matters of concern are as follows:  

1.  Lack of appropriate monitoring of Mia during the night.  

Mia’s  underlying  illness  caused  seizures  which  were  multifocal,  complex  and  variable 
from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated 
that  carers  should  enter  her  room  every  15  minutes  to  undertake  visual  observations 
throughout the night to ensure Mia was in a safe position, was breathing and not at risk 
of asphyxiation.  

However, this did not take place as frequently as specified. Moreover, it was common 
practice amongst some carers to review images from a video monitor placed over Mia’s 
cot  rather  than  direct  visualisation  despite  it  being  recognised  that  the  monitor  was 
insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe 
from asphyxiation. 

2.  Mia’s medical records at The Children’s Trust were neither comprehensive nor easy to 
understand  and  did  not  conform  to  the  expected  standard  in  NHS  general  or hospital 
practice to ensure accurate and contemporaneous medical care was being reviewed and 
documented.  

Mia was a ‘looked after’ child with complex and challenging health needs and could not 
contribute  or  make  decisions  for  herself.  Regular  PEWS  (Paediatric  Early  Warning 
Scores) assessments were not undertaken to ensure Mia’s well-being despite it being 
within her care plan.  

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  was  reviewed  by  a  ‘privately  funded’  consultant  employed  by  but  working 
independently  of  Great  Ormond Street  Children’s Hospital as and when  requested by 
the medical staff at The Children’s Trust. The consultant had no terms of reference and 
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 not available from 
April to October 2023.  

In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure 
her  ongoing  medical  needs  conformed  to  expected  practice  nationally  and  for  an 
independent consultant outside of The Children’s Trust to have regular oversight and co-

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ordinate  investigations  and  any  further  multi-disciplinary  management  she  may  need 
given this progressive life limiting condition. 

3.  Senior management at The Children’s Trust, Tadworth. 

The lack of a robust and adhered to care plan for night observations for Mia mirrors the 
same concern in the Prevention of Future Deaths report I issued following the Inquest 
touching on the death of Connor Wellsted at The Children’s Trust in 2022. 

The Independent investigator commissioned by The Children’s Trust highlighted ongoing 
clinical  governance  limitations  including  the  initial  management  and  investigation  of 
Mia’s  death,  delay  in  fulfilling  the  Duty  of  Candour’  obligations,  ongoing  staff training, 
ensuring robust procedures were in place alongside regular audits of clinical practice.  

Regulation 29:  Response  from The  Children’s Trust, Action  to  Prevent  Future  Deaths, 
Mia Gauci-Lamport 

The tragic death of Mia has deeply affected all of us at The Children’s Trust and our thoughts 
continue to extend to Mia’s family and loved ones. We fully acknowledge the importance of the 
coroner’s concerns raised in the Prevention of Future Deaths report and take this and every 
opportunity to review our practices and ensure that lessons are learned.  

We  are  committed  to  continuously  improving  our  services,  strengthening  our  systems,  and 
ensuring the highest standards of care for the many families and carers who put their trust in 
us, and to working in partnership particularly with the children in our care and their families. 

We have taken immediate and comprehensive steps to address the areas raised in the report. 
We acknowledge that whilst significant improvement work has been undertaken in these areas 
in  recent  years,  further  work  was,  and  is,  still  needed.    This  response  outlines  the  actions 
already taken and the improvements we continue to make. 

We  remain  focused  on  creating  an  environment  where  children  with  complex  needs  receive 
care that meets the highest standards, and we are fully engaged with external stakeholders to 
ensure  that  our  practices  are  aligned  with  the  most  current  guidelines  and  evidence-based 
practice. Since the inquest, The Children’s Trust has been inspected by Ofsted Care who rated 
the residential care provided to the children and young people as Good.   

Action Taken by The Children’s Trust 

Review and Update of Care Plans and Monitoring Protocols 

A  comprehensive  review  of  our  monitoring  protocols and  individualised  care  planning 
process has been undertaken which has led to several critical actions being identified, 
all of which are now overseen by robust internal governance: 

o  Policy and Clinical Guideline: The Frequency of Monitoring Policy has been initially 
reviewed and updated to ensure it is clear and consistent and can be individualised 
for  each  child  through  specific  clinical  guidelines.  This  ensures  monitoring 
practices  are  personalised  to  meet  each  child's  unique  needs  and  based  on 

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 individualised risk assessments.  Further work is now needed to align the policy 
with  national best  practice  relevant  to  the  unique  care  setting  at  The  Children’s 
Trust.  This work has commenced and requires wider input and critique to ensure 
that  a  significant  and  safe  revision  to  our  approach  and  policy  is  designed  and 
implemented.  

o  Monitoring  Tools:  A  review  of  monitoring  tools,  including  video  surveillance  and 
wearable sensors, has been completed. We continually ensure that these tools are 
appropriate for each child's needs and used correctly to provide effective oversight 
without  replacing  appropriate  checks.    This  initial  action  is complete  and  is now 
continuously reviewed and audited in line with evidence-based practice. 

o 

Individualised  Care  Plans:  We  have  made  certain  that  care  plans  are  clear, 
individualised,  and  regularly  updated  based  on  the  child’s  current  needs  and 
challenges  and  aligned  to  the  PEWS  (Paediatric  Early  Warning  Scores).  These 
updates  ensure  that  the  monitoring  of  children  is  consistent,  personalised,  and 
aligned with the latest clinical guidelines.  This initial work is complete and is now 
continuously reviewed and audited in line with our policy and best practice. 

o  Shift Handover Protocol: A revised Shift Handover Protocol has been introduced 
to ensure that the level of supervision and observation required for each child is 
understood and clearly communicated during shift changes. Additionally, the last 
set  of  clinical  observations  from  the  prior  shift  are  recorded  and  discussed  at 
handover, ensuring a seamless transition and continuity of care.  This protocol has 
been embedded across The Children’s Trust and is subject to continuous review 
and audit to ensure compliance. 

o  Frequency of Monitoring and PEWS Practice Audits: We have implemented new 
Frequency  of  Monitoring  Practice  audits  overnight,  conducted  by  Clinical  Site 
the  monitoring  and 
Managers.  This  ensures  continued  compliance  with 
observations policies. These audits are complemented by monthly quality walks to 
ensure the consistent implementation of care plans and protocols.  This additional 
assurance  mechanism  is  built  into  roles  and  responsibilities  and  findings  from 
these audits feed into the broader clinical governance framework. 

o  Reporting and External  Oversight: The results of  relevant audits are reported to 
both The Children’s Trust regulators, The Care Quality Commission and Ofsted, 
monthly,  ensuring  external  oversight  and  accountability.  Furthermore,  we  are 
working  with  the  wider  health  and  social  care  system  to  continually  revise  and 
improve  our  protocols,  ensuring  they  are  evidence-based,  benchmarked,  and 
consistent with the best practices in residential settings. This work continues and 
is taking place through existing NHS governance frameworks. 

Integration and Multidisciplinary Working  

Recognising the need for greater integration with NHS services, particularly for children 
with complex health conditions such as epilepsy, we have already taken significant steps 
to  strengthen  our  collaboration  with  NHS  partners  to  ensure  the  children  and  young 
people in our care have equal access to NHS resources and expertise: 

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 o  Enhanced NHS Integration: The Children’s Trust is actively working with primary, 
secondary and tertiary  NHS services to ensure that children in our care receive 
timely and regular access to care. We are working with the wider health and social 
care system to formalise clearer referral pathways and improving coordination with 
NHS  specialists  to  ensure  that  all  clinical  needs  are  addressed  promptly.    This 
through  existing  NHS  governance 
work  has  commenced  and  continues 
frameworks. 

o  Reducing Reliance on Private Consultants: We are actively reducing our reliance 
on  private  consultants  for  ongoing  care,  particularly  in  areas  such  as  epilepsy 
management,  and  are  working  to  ensure  that  children  receive  care  that  is  fully 
integrated within the NHS. We have required wider health and social care system 
support to ensure equitable access for the children and young people in our care 
and this work continues. 

o  Multi-disciplinary  Care  Model:  We  are  working  with  the  broader  NHS  system  to 
improve integration across the whole care pathway and ensure that this is multi-
disciplinary across medical, nursing and care and therapy, and not focussed solely 
on the medical care for the children and young people. Whilst we have a strong 
internal multi-disciplinary care model focussed around the care of the children, we 
have  also  taken  the  opportunity  to  commence  a  detailed  review  of  our  internal 
model alongside broader integration. 

o  Medical  records:  We  continually  audit  our  medical  records  in  line  with  NHS 
standards and achieve high compliance against these. As an organisation sitting 
outside the NHS, health record integration is complex and an ongoing area of focus 
for us with our wider health and social care system partners.  Medical record audits 
continue regularly to ensure our ongoing compliance in this area. 

Leadership and Governance Improvements 

The Children’s Trust is committed to maintaining and improving robust governance and 
oversight systems. We have initiated a series of improvements: 

o  Strengthened Governance Framework: We have reviewed and begun to refine our 
clinical  governance  structure  to  ensure  that  all  care  practices  are  subject  to 
rigorous oversight and that systems are in place to monitor adherence to protocols 
and  standards.  This includes  strengthening  review  processes  and ensuring that 
leadership is engaged in overseeing the implementation of improvements.  This 
programme of work is in process with some immediate actions taken. 

o  Regular  Audits  and  Reviews:  To  support  sustained  improvement,  we  have 
introduced regular audits to assess the quality of care, the implementation of and 
adherence to care plans, and the effectiveness of our monitoring practices.  This 
work  continues  and  is  scrutinised  both  internally  and  by  our  external  regulators 
and commissioners. 

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 o  Thematic review: We have undertaken a thematic review of all serious incidents 
and  near  misses  within  a  specific  timeframe.  The  themes  and  trends  identified 
through this review have resulted in dedicated workstreams being embedded into 
the  existing  governance  structure.  The  thematic  review  is  currently  in  the  final 
stages of completion and has focussed on the embedding of continuous quality 
improvements. 

System-Wide Risk Summit  

In response to the Coroner’s Regulation 28 report, The Children’s Trust called a System-
Wide Risk Summit which was held on November 14, 2024. The summit brought together 
a wide range of external stakeholders, including NHS England, NHS providers as well 
as social care partners, commissioners, regulators, and expert consultants.  

The  summits'  goal  was  to  discuss  the  concerns  raised  by  the  coroner  and  identify 
actionable  steps  to  strengthen  care  practices,  ensuring  that  The  Children’s  Trust’s 
processes are aligned with national standards and evidence-based practice. 

The summit focused on two key areas: 

Medical Care Provision for the Children and Young People:  

o  The  summit  discussions  highlighted  the  challenges  in  relation  to  the  integration 
with broader NHS paediatric services for the children within residential care at The 
Children’s  Trust.  This  was  particularly  explored  for  complex  conditions  such  as 
epilepsy. It is essential, for us and the wider system, to recognise that children in 
our care are entitled to the same standard of, and access to, NHS services they 
would  receive  elsewhere.  The  identified  gap  in  access  to  NHS  paediatric 
specialists in the management of epilepsy, is being urgently addressed as part of 
ongoing  work with  system  colleagues.  The Children’s Trust has  taken  proactive 
steps  in  collaboration  with  NHS  partners  to  ensure  equitable  access  to  NHS 
services,  upholding  the  parity  of  care  and  ensuring  children  receive  appropriate 
care alongside and enhancing the medical provision provided by The Children’s 
Trust. 

Monitoring and Observation of Children and Young People 

o  The summit examined the current practice and policy in relation to monitoring and 
observation, particularly around night-time care, and explored ways to ensure that 
care  plans  are  adhered  to  consistently  as  well  as  what  is  appropriate  within  a 
residential care setting for medically stable children. There was clear recognition 
that  wider  health  and  social  care  system  support  as  a  critical  friend  is  readily 
available  in  relation  to  this  complex  issue,  and  that  the  current  policy  and 
processes in place far exceed those within a variety of healthcare settings.  Further 
revisions  to  the  policy  are  planned  following  ongoing  engagement  with  system 
partners. 

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 Ongoing Actions 

To ensure that improvements are embedded within The Children’s Trust, the following ongoing 
actions (also detailed within the narrative above), have been identified: 

1.  Integrated Multi-Disciplinary Care Model 

o  Action:  Further  strengthen  integration  with  NHS  services  to  ensure  equal  and 

timely access to care for children with complex health needs. 

2.  Monitoring and Observation 

o  Action:  Further  revise  monitoring  protocols  and  care  plans  in  line  with  best 

practice and with wider system engagement and support. 

3.  Governance and Policy Development 

o  Action:  Further strengthen clinical governance frameworks and ensure  ongoing 

and robust oversight of all care practices. 

Summary 

We  remain  committed  to  ensuring  the  highest  standards  of  care  for  all  children  and  young 
people at The Children’s Trust. We fully recognise the importance of the concerns raised in the 
Coroner’s Regulation 28 report and have taken immediate steps to enhance our practices and 
systems.  Through  collaboration  with  our  NHS  and  wider  system  partners,  continuous 
engagement with stakeholders, children and families, and a strong focus on improving clinical 
governance, we are confident that these changes will result in  tangible improvements to the 
care we provide. 

We remain fully engaged in this process and will continue to review and refine our practices to 
ensure that all children receive the safest, highest quality care possible. 

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