She died in hospital on June 1, 2023, three days after she went into cardiac arrest whilst she was left unsupervised at the care home.
Raihana’s mum, Latifat Kehinde Solomon, had repeatedly raised concerns that her daughter was not receiving the around the clock one-to-one care which doctors had decided she needed.
Senior coroner Professor Fiona Wilcox said “on the balance of probabilities” Raihana would not have died if she had been properly observed.
On the evening of May 29, 2023, records showed that the nurse responsible for Raihana’s supervision left to complete some admin work.
A nurse was asked to cover but her shift had ended, so she asked another colleague and ultimately Raihana was left alone.
When the nurse returned from her admin task after 15 minutes Raihana was found in cardiac arrest and was rushed to St George’s Hospital in Tooting where she died.
Prof Wilcox also raised concerns that “may be a culture of cover up” at The Children’s Trust.
“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,” Prof Wilcox said.
Raihana’s cause of death was given as natural causes contributed to by neglect.
Mike Thiedke, chief executive of The Children’s Trust, said: “Raihana was not being observed to the standard that the organisation would expect in the period immediately before she was found unresponsive on the evening of May 29, 2023. We unreservedly apologise to Raihana’s family for these failings.
“Raihana’s mother raised serious concerns about her daughter’s care which were not acted upon or managed properly, and for that we are truly sorry.
“Her loss has had a profound effect on the way we care for, support, and involve the children and families we work with today.
“Actions we have taken following this heartbreaking experience include completing a thorough review of our care, substantial improvements to staff training, and putting in place a stronger system to make sure families are heard – especially when they raise concerns.
“In partnership with our regulators and the wider healthcare system, we have changed how we monitor and observe children and young people and increased frontline staffing levels.
“Our thoughts remain with Raihana’s family during this time.”
A spokesperson for Croydon Council said: “Our first thoughts are with Raihana’s family, and we want to express our deepest condolences for their devastating loss.
“Raihana was placed at The Children’s Trust so she could receive 24-hour care for her complex needs and we worked to ensure Raihana’s mother was included in reviews, her voice was heard and any concerns addressed.
“Despite this, and the assurances we received from the trust, it is clear that the care they provided fell below our expectations.
“Following internal reviews, the trust has changed its processes around staffing and one-to-one care and we will continue to work with them to ensure that lessons have been learned from this tragedy.”
