Raihana Oluwadamilola Awolaja
2 May 2025 · Coroner Fiona J Wilcox · Inner West London
The coroner's concerns
1. insufficient supervision of children requiring one to one care
“children such as [the deceased] requiring one to one care are still at times receiving less intensive care and supervision than they require”
2. flawed investigation shifting blame
“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.”
3. inadequate communication with stakeholders
“TCT do not sufficiently communicate with the commissioning LA nor next of kin in relation to issues with care and supervision, for example not informing the named social worker nor the mother of the disciplinary proceedings against a staff member who left [the deceased] alone”
4. training gaps in one to one care definition
“staff training issues in relation to what one to one care means in practice”
5. administrative prioritisation over care
“training issues in relation to the prioritisation of administrative tasks above care”
6. dismissal of next of kin concerns
“next of kin are not sufficiently listened to when they raise concerns, and their complaints are dismissed without sufficient investigation”