Rose Harfleet
13 May 2025 · Coroner Karen Henderson · Surrey
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate management of children with profound disabilities
“The management of children with profound disabilities within a hospital setting”
2. failure to consult parents and guardians of children with profound disabilities
“The importance of obtaining this information was not understood by the paediatric consultant who took no history from [the deceased]'s motherand underestimated the severity of her signs and symptoms”
3. dismissal of parental advocacy for disabled children
“the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting”
4. absence of learning disability liaison nurse support
“there was no consideration or offer given to [the deceased] or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse”
Linked reports
Identical hazardConfidence 0.92 · high
Earlier report
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people”
This report
“there was no consideration or offer given to [the deceased] or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse”