Sheffield boy Connor Wellsted, five, died in cot bumper tragedy at The Children's Trust hospital, Surrey

Little Connor Wellsted was found sat upright in his cot on the morning of May 17, 2017, at The Children’s Trust rehabilitation centre in Tadworth.

He had been dead for ‘at least an hour’ when he was found after an ‘inflexible’ cot bumper had come loose and got stuck over his neck.

Now, Connor’s foster mum from Sheffield, Barbara Harriott, has paid tribute to the “special little boy” – and told of the frustration at waiting over five years to see his inquest completed.

"He was an absolute pleasure to look after,” said Barbara. “He was so joyful.

"He was a loveable rogue, is the best way I could put it. He was a little boy with a larger than life character.”

Connor, who had multiple complex health conditions after suffering a brain injury from asphyxiation at five weeks old, came to Barbara’s care in 2012.

Doctors told her they did not expect him to live long, but she became his permanent foster carer for over four years at her home in Ecclesall.

"I always felt he was able to see me even though we were told he was blind,” said Barbara. “I used to sign a ‘B’ for Barbara with my hands and one day he started putting his hands together in a clumsy ‘B’. He had a range of signs, at least 300, to show what he wanted.

"He loved school and nursery. He had such a strength to him, more like willpower. It was obvious he wanted to walk but didn’t have the muscle strength.”

Connor began a six-week therapy course at The Children’s Trust in April 2017 to improve his mobility.

Tragically, four weeks into his stay, Connor was found dead in his cot on May 17.

It is believed the five-year-old may have grabbed the 2kg bumper around his safety cot, causing it come loose and leave him stuck.

Barbara said: “I remember them calling that morning and saying ‘we need to talk to you’.

“I was initially panicked, but my room was right by the hospital and I hadn’t heard an ambulance. I calmed myself down and figured they wanted to talk about his food.

"When I arrived they took me to a room and said ‘we’re sorry but Connor has died in his sleep’.”

At the conclusion of his inquest at Woking Coroner’s Court on April 5, assistant coroner Dr Karen Henderson ruled the Trust “failed to keep Connor safe” by not properly securing the bumper.

She also scolded the Trust for “significant lapses in care”. Evidence heard how nurses did not check on him visually, and at one point only opened the door to “sniff” to air to see if he needed changing.

She added it was “wholly inadequate” how the cot had not been serviced in four years, and called out the hospital’s “patent lack of transparency” during the investigation.

The Trust was also said to have “misled” the Care Quality Commission when it wrongly reported that nurses checked on Connor every 15 minutes.

“The Trust actually is an amazing place,” said Barbara. “But people were entrusted with Connor and they let us down. I can’t go back and change that I took him there.”

But for Barbara, the most frustrating aspect was the five-year delay in bringing Connor’s inquest to a conclusion.

In fact, a hearing was held to find Connor’s cause of death in 2018 – where it emerged neither the coroner. the police, or even the Trust had the full facts.

Earlier evidence in that hearing claimed Connor had been found lying in his back, and a pathologist ruled he died in his sleep of accidental mechanical asphyxia.

However, when the nurse who found him took the oath to give evidence, she reported – to the shock of Barbara, Connor’s family and the coroner – that she had found him sat upright with the bumper across him, meaning he could not have died in his sleep.

The coroner ordered an adjournment to investigate, leading to the hearing in April 2022 – five years after the little lad’s death.

Barbara said: “When he was found sat up, the nurse didn’t call 999 right away, but asked for another nurse to come help.

"She then said to call 999, and 999 said to lay him on his back.

"They moved him, which was a mistake, and lay him on his back, and a doctor came and pronounced him dead.

"Somehow, the crucial bit of information of how he was found was lost in all this. The police didn’t know, the coroner didn’t know, and everyone was under the impression he was found lying down.

"I just don’t know how he was let down by all these systems. He was not an ordinary little boy – he was a child who needed care. In all that time, you would think the Trust, or social services, or the coroners, or somebody somewhere should be interested and look into it.”

Following the inquest, The Children’s Trust was made the subject of a Preventing Future Deaths report. Dr Henderson commented: “It is the lack of acceptance, understanding, acknowledgement and the lack of trust and care that you provide these individuals who are all vulnerable which is of great concern to this court and it requires me to write a report."

A spokesperson for the Trust said in a statement their thoughts were with Connor’s family and their staff who were all “greatly affected by Connor’s death”, and it would do “everything in our power to ensure something like this can’t happen again.”