Connor Wellsted

1. 1. inadequately secured padded board entrapping child

   “The cot [the deceased]'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”

2. 2. lack of nighttime visual monitoring

   “[the deceased] 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.”

3. 3. inadequate incident preservation and communication

   “Tadworth The Police and the coroner's service attending the Trust shortly after being informed of [the deceased]'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 [the deceased] 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”

4. 4. failure to preserve evidence and notify authorities

   “[the deceased]'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 [the deceased]'s death. However, they did not keep a copy of [the deceased]'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 [the deceased]'s death.”

5. 5. incomplete information to expert

   “the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in [the deceased]'s death. The”

6. 6. lack of accountability and transparency

   “The current senior management team have not acknowledged there was a lack of transparency and openness as to how [the deceased] 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.”

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