Thread by @GeorgeJulian

Twitter, I'm afraid I've another utterly harrowing and heart breaking tale to tell you, but I hope you'll read, reflect and share. It's so important. You can read it all here, but I'll thread some of it too

georgejulian.co.uk/2022/06/29/con…

Connor Wellsted: our boy for ever more

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I’d like to tell you about a little boy called Connor Wellsted. I spoke to one of his foster parents, Shazia @truth4connor and she told me about Connor, his life, and what is understood about his death @Childrens_Trust aged just 5, now his inquest is finally complete.

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Connor was born in April 2012 in Sheffield, he was born prematurely and acquired a brain injury shortly after birth following a cardiorespiratory arrest which starved his brain of oxygen.

Connor lived with significant disabilities, but he was loved, and enjoyed life.

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In November 2012 Connor went to live with Barbara and Shazia, who became his permanent foster parents. It’s clear from talking with Shazia that they were extremely loving and loved having Connor in their lives.

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Connor thrived with their support and developed more than some had expected.

Connor signed to communicate and said a few words.

He was a very happy little boy and was progressing well.

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When Connor was 2.5 he really benefitted from a stay at @Childrens_Trust. They had always said Connor and his family were welcome to return, so in early 2016 his carers felt it would be a good time to reapply for him to go.

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“We thought we were doing the best thing for him, to go there”

It took nearly a year for the CCG to process his application for a further period of rehabilitation, and eventually on 19th April 2017, Connor and Barbara started a planned 6 week stay.

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“Couldn’t fault what he was getting there, in terms of therapeutic input. He was there to receive what we thought was the best care. He’d been there 4 wks. He’d been well but had few issues, like he had diarrhoea. He got a very, very sore bottom. We were concerned about that”

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Shazia explained the overnight set up at @Childrens_Trust. Children receiving rehabilitation would stay in units, houses. Up to six children per house who were cared for by the staff overnight. Parents accommodation was in a separate block.

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During the day Barbara or Shazia looked after Connor, unless they were on a break or eating a meal. They attended all the therapy sessions, during the daytime with Connor, but from bedtime the staff took over the care.

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At Connor’s inquest, much emphasis was placed on the fact that @Childrens_Trust is not a hospital. They tried to use that in their defence and argued that Article 2 did not apply to Connor’s inquest.

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They suggested that as they were a charity, they were not a public authority under the Human Rights Act as providing services for the benefit of the public doesn’t constitute a “function of a public nature”.

This felt hollow to Connor’s foster parents.

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The @Childrens_Trust employed trained nurses, acknowledged and recognised that the children in their care were all vulnerable as a result of brain injuries.

Connor’s stay was totally #NHS funded, and the care was regulated by the @CareQualityComm.

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The Assistant Coroner for Surrey, Dr Karen Henderson, took submissions from both sides before ruling that Article 2 did apply.

So what happened to Connor?

Shazia had visited for 5 days the week before, switched positions with Barbara on the Sunday.

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Barbara was with Connor during the day time, the night before he died they went out for a cycle ride and Connor was his usual happy self.

Nothing was untoward or strange that evening.

Twelve hours later their lives were turned upside down.

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Shazia explains how they were initially told that Connor had been checked an hour before his death, by a carer who told other staff that he was still sleeping.

During his inquest a different picture emerged

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“It transpires... she didn’t see Connor in the cot, she saw a cuddly toy, his fluffy bunny rabbit… he couldn’t have been in the position to be seen from the door, he was right in the corner of his cot, wouldn’t have seen from doorway".

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"He’d probably been there hours and hours given the fact he was in rigor mortis. He’d developed other signs of death, livor mortis, the blood pooling”

It's apparent following Connor's inquest carers had gone into his room in the dark, to give him his medication after 8am

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Shazia explains the inquest opened in April 2018, but was adjourned when a nurse took the stand:

“She initially said the cot bumper was on Connor’s chest… she eventually said it was under his neck…but it became clear it was stuck there and required force to remove it”

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The coroner asked the nurse to return to the stand. She then changed her evidence from the bumper being on Connor’s chest, to being under his neck.

Shazia recalls the support from @AvMAuk who had provided a barrister in training pro-bono for the initial one day inquest

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The same barrister stuck with the family through the next four years until Connor’s final inquest hearing took place. She is certain that they would not have uncovered what was found without their help.

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Shazia describes chaos, carers and nurses calling for help but not pressing emergency buzzers

“In witness statements they do describe when they laid him down his legs were sticking up in the air…

This is what they’re saying, this is what the inquest has apparently found"

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"They moved Connor’s body, removed his sleeping bag, when Barbara went to his room he was not in his sleeping bag.. was nowhere to be seen, turned up day or two later back in his room. So they removed his sleeping bag, and manipulated his body to lay him in a flat position"

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Not only is remembering confused and contradictory, the narrative of parent blame emerges early.

“Very cruelly after Connor died they didn’t immediately say what happened, but excused their lack of checks... saying foster parents didn’t want us to disturb Connor overnight”

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These narratives quickly take hold.

In the root cause analysis in the serious incident review, the question asked was:

“how can we prevent a situation where parents tell us not to check overnight”

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The carer who was charged with checking Connor at 7am, who looked from the door and didn’t actually see him, told Police that she:

“didn’t disturb him any further because his foster parents like us to let him wake naturally”.

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As is so often the case when disabled people die, @SurreyPolice didn’t really appear to do any thorough investigation.

“Junior police officers complete their investigations, they talk to various people, don’t interview everybody. The sudden death report was incomplete"

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"The phrase “exceeded his life expectancy” the Detective Sergeant had conveyed back to the police officers there, that he doesn’t need to attend, this is a place for sick children”

[How many times? Natural causes? Had a good innings? Nothing to see here]

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Shazia wrote to @IOPC_Help to make a complaint about how police had failed to really investigate what happened to Connor.

They conceded they shd have questioned more but fell back on the findings of the pathologist, who in turn had not been made aware how Connor was found

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Shazia describes inconsistencies between what they saw and the narrative that emerged. Blood pooling in Connor’s hands/lower limbs particularly concerns her.

“I’m a doctor, a GP, I’ve verified people’s deaths, never in my life have I seen someone in the condition he was in"

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"It was like he had strange markings on his body… blood pooling in his hands and lower limbs, it just wouldn’t fit with him being laid down as they claimed”.

The coroner found Connor died sitting upright in his cot, trapped by the bumper, not accepting evidence from staff

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She said “I am satisfied the position of the bumper was on Connor’s neck and given the demonstrable inflexibility and rigidity of the bumper… that it took some force to be able to release the cot bumper and it was entrapping him”.

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The coroner considered the claims the bumper was found on Connor’s chest was misleading and inaccurate.

She was critical of the damage these false narratives caused to her investigation, and that of the police and the pathologist.

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She also criticised the lack of curiosity and resulting failure share possible circumstances that may have contributed to Connor's death:

"the lack of curiosity by those on duty and more particularly by those in senior management who had a duty to undertake a full enquiry"

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It seems to me that criticism could be extended to so many others.

Such apathy, so little genuine curiosity about how a child can go to bed and die hours later.

The coroner issued a Prevention of Future Death Report which is explicitly critical judiciary.uk/wp-content/upl…

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In it she states:

“Connor was known to be an active boy and it is likely he had woken, stood up and held onto the cot bumper which was not fixed at the top edge which then became dislodged entrapping him across his neck”

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She raises concerns about the unsafe use of the cot.

The coroner is also critical about the fact that there were no proper checks of Connor overnight.

In court she stated that the overnight supervision of Connor was:

“inadequate and unsafe"

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"I do not accept that by opening a door and/or standing near the door and/or sniffing the air is a proper assessment of Connor particularly as there was a wish and a need to ensure Connor was not lying in a dirty nappy”

The Coroner accepted it was sub optimal care of Connor

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However, you know what's coming.

Ultimately she felt she was unable to make a finding that the lack of supervision contributed to Connor’s death, as she accepted evidence Connor was likely to have died very quickly once he was trapped in the cot.

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The coroner accepted it leaves what-if questions, as to how things may have been different if regular checks had been undertaken.

The PFD raises two ongoing concerns in relation to the probity of @Childrens_Trust and in terms of the senior management team

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“The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved"

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"They were not told of the position Connor 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 to be removed"

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"Connor’s death was sudden and unexpected, and the senior management of @Childrens_Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records"

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"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 Connor’s death”

Does it get more serious than this? Misleading @CareQualityComm

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I have to say if I was @CareQualityComm receiving this PFD report, the only logical next step would be to investigate prosecution.

For failings in care, and also failings in Duty of Candour, worse still active attempts to mislead. Fraud I guess.

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Likewise if I were the @nmcnews or @gmcuk in the case of the Medical Director, I’d want to investigate further.

How can anyone, regulators, or the public, have confidence in the care being provided to vulnerable children when this is the response to a death on their watch?

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Thinking about it I think I’d want to know more if I was the @ChtyCommission too.

Too many charities provide poor care with seemingly no consequence eg

https://twitter.com/GeorgeJulian/status/1539570890442260481

and

https://twitter.com/GeorgeJulian/status/1539929686125453312

for two threads detailing recent reports about @mencap_charity 'care'

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The problem with these omissions and cover ups, narratives of parent blame, is they take on a life of their own.

They breed and multiply, in no time there is no thorough investigation, just a lifting of the ‘deaths from natural causes’ cover-up cloak, to sweep them under

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The coroner continued:

“Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death".

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"In addition, the @Childrens_Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death"

Surely deliberately misleading a medical expert is fraud?

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"@Childrens_Trust undertook several Serious Investigation reports... these reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant”.

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I just cannot comprehend how that can be viewed as anything other than a deliberate fraud and cover-up.

Wilful.

Deliberate.

The coroner was also explicit about her ongoing concerns relating to senior management @Childrens_Trust:

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“Current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died, or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death"

cc @ChtyCommission

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"concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by @Childrens_Trust... need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies"

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"that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency”.

Coroner had decided Article 2 did apply, because @Childrens_Trust were a hybrid public authority.

@SurreyPolice are also a public authority.

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How can two public authorities fail to investigate the death of a child?

Not to mention fact Connor was a looked after child, in the care of the state, in foster care @SheffCouncil

There should have been people falling over themselves to find out what happened to Connor

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Shazia @truth4connor is conflicted with the inquest process.

While grateful that the Coroner was able to find facts, and that she was critical of what they consider to be a cover up, it still feels insufficient.

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@Childrens_Trust had disposed of Connor’s bed before the initial inquest took place.

Claiming they didn’t believe it had anything to do with Connor’s death.

A bed that turns out had not been serviced for 5 years.

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@Childrens_Trust claimed they cld not trace who the bed supplier was, altho in one of staff statements a serial number was mentioned.

Frustrated at the partial exploration, following Connor’s inquest, Shazia made her own enquiries and did her own investigations

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“They confirmed they supplied the bed to @Childrens_Trust in 2009 and that they made the padding for the bed. Initially they made padding 2/3 of height of the bed, but they went back months later, on request of TCT and fitted padding to the full height of the bed”.

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So, @Childrens_Trust disposed of the bed, and claimed they didn’t know where it came from, but a bereaved family member is able to not just track it, but also uncover that the padding was bespoke, made on the instruction of the Children’s Trust.

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I’m not legally qualified, but to me, that seems like they should be even more responsible for this failing.

Surely this is the exact sort of failing that the @CareQualityComm should be actively pursuing?

The coroner’s conclusion reads:

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Connor Samuel Timothy Wellsted had significant neuro-disabilities and was attending Tadworth @Childrens_Trust for a period of intensive neuro rehabilitation. He died 08.42 hours 17 May 2017 following entrapment by a loose cot bumper causing death by way of airway obstruction

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I am satisfied that the @Childrens_Trust failed to

1. Properly secure the cot bumper appropriately and in so doing

2. Failed to keep Connor safe in his cot

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How can it be that a young child can die in their care, and the self-appointed @Childrens_Trust “UK’s leading charity for children with brain injury” can be so care less about establishing what happened?

How can this be?

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I'll leave you with a video of Connor. Pure joy, showing Connor being loved, and loving being loved, by those who cared for him. Singing and camping, living his best life.

Pls follow @truth4connor and share this thread so others know

#braininjury #DeathByIndifference

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