A coroner has ruled that neglect contributed to the death of 12-year-old Raihana Awolaja, who suffered a cardiac arrest after she was left unsupervised at a specialist care home in Surrey.

Raihana, who was born prematurely in Romford in 2011 and had complex medical needs, died in hospital on June 1, 2023, three days after she collapsed at a care home operated by The Children’s Trust in Tadworth.

The care home was commissioned by Croydon Council, which had responsibility for Raihana’s welfare under a care arrangement.

“She should have been observed”: Coroner delivers damning verdict

Senior coroner Professor Fiona Wilcox concluded that “on the balance of probabilities” Raihana would not have died had she been properly observed, and that her death was the result of “natural causes contributed to by neglect.”

The inquest heard that on the evening of May 29, 2023, the nurse assigned to provide one-to-one care for Raihana left to carry out administrative work. While cover was supposedly arranged, the nurse initially asked had completed her shift and passed the responsibility on to another colleague — ultimately leaving Raihana unsupervised for approximately 15 minutes.

When the nurse returned, Raihana was in cardiac arrest. She was rushed to St George’s Hospital in Tooting, where she tragically died three days later.

Mother’s warnings were ignored

Raihana’s mother, Latifat Kehinde Solomon, had repeatedly raised concerns with both the trust and the council that her daughter was not receiving the constant one-to-one supervision that her doctors had said she required.

Despite these warnings, her pleas were reportedly ignored.

Coroner raises fears of a “culture of cover-up”

In a scathing assessment of the aftermath, Prof Wilcox said she believed there “may be a culture of cover-up” at The Children’s Trust. The organisation, she said, had “pushed blame onto an innocent individual” in a flawed internal investigation, rather than confronting systemic failings.

“They carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths,” she added.

Children’s Trust and Croydon Council respond

In a statement, Mike Thiedke, CEO of The Children’s Trust, admitted serious failings:

“Raihana was not being observed to the standard that the organisation would expect… We unreservedly apologise to Raihana’s family.”

He acknowledged that Raihana’s mother’s concerns had not been properly managed and detailed a number of reforms now in place, including:

• A full review of care procedures
• Increased frontline staffing
• Better systems for responding to family concerns
• Enhanced training and observation protocols

Croydon Council also issued a statement expressing deep regret:

“Despite the assurances we received from the trust, it is clear that the care they provided fell below our expectations.”

The council confirmed that it is continuing to work with the trust to ensure lasting change.

A preventable tragedy

Raihana’s death highlights ongoing issues in the care system, particularly around the oversight of vulnerable children placed in external care homes.

As families, charities, and professionals continue to call for better regulation and accountability, Raihana’s story serves as a tragic reminder of what can go wrong when early warnings are dismissed and systemic failures go unchecked.

 If you have concerns about care standards or child safeguarding, you can contact Ofsted or the NSPCC at 0808 800 5000.