Alder Hey Hospital has accepted full responsibility for 24 separate failures in care that contributed to the death of 21-month-old Eleanor Hazel Aldred-Owen. The Liverpool children’s hospital trust issued a public apology after an investigation concluded that the toddler’s death was preventable and resulted from neglect.
Eleanor died on October 2, 2023, following routine surgery for craniosynostosis, a condition affecting skull development. A coroner ruled that she died as a result of misadventure, with neglect playing a significant role in the outcome.
Missed Warning Signs and System Failures
The investigation revealed a chain of errors during Eleanor’s recovery. Although the initial surgery proceeded without major issues, an abnormal chest X-ray taken during recovery was not flagged by the radiographer. The attending doctor did not review the results immediately because she was attending to another child in the emergency department.
During this time, Eleanor experienced a raised heart rate and required oxygen. Staff initiated AIRVO, a high-flow humidified oxygen therapy, but the treatment was not properly documented or prescribed according to hospital guidelines. Eleanor subsequently suffered a collapsed lung and a cardiac arrest, leading to an unsurvivable brain injury.
Key failures included the incorrect calculation of the Paediatric Early Warning System score on multiple occasions. Correct scoring would have triggered an earlier medical review and chest X-ray assessment. The trust acknowledged that missed opportunities to escalate the abnormal X-ray findings were central to the tragedy.
Family Response and Hospital Reforms
Eleanor’s parents, Rachel and Chaz Aldred-Owen from Mold, Flintshire, described the period following her death as filled with unbearable guilt and trauma. They stated that their lives have been irreversibly changed, noting that they grieve not only for their daughter but for the people they used to be.
Chaz Aldred-Owen said that the trust’s admission of gross neglect was the hardest part of the process. He noted that the family had been at the mercy of the information provided by the hospital for a long time. He emphasized that the true victory lies in ensuring that no other family has to endure a similar experience.
In response to the investigation, the trust has implemented new safety measures. These include a clear escalation process within the radiology department for grossly abnormal and time-critical findings. Two post-operative procedures have also been introduced at the hospital and named after Eleanor.
Lynda Reynolds, the family’s solicitor, described the case as unimaginably tragic. She stated that while the trust’s acceptance of responsibility and apology are important, the family hopes the implemented changes will be kept under review to ensure they make care safer for other children.
The trust expressed that the loss has left a permanent mark on its staff. They stated they are heartbroken that they failed Eleanor and her family and are committed to preventing such a tragedy from happening again.
Source: BBC
