Alder Hey hospital admits responsibility for Mold girl’s death

Alder Hey Children’s Hospital NHS Foundation Trust has formally admitted full responsibility for 24 critical failures that led to the tragic death of 21-month-old Eleanor Hazel Aldred-Owen. Eleanor tragically passed away at Liverpool’s Alder Hey Hospital on October 2, 2023, with a coroner later concluding her death was a result of misadventure, significantly contributed to by neglect. The young child had undergone routine surgery for craniosynostosis, a birth defect affecting the skull, but a subsequent abnormal chest X-ray was inexplicably not flagged, a devastating oversight that ultimately proved fatal. Eleanor suffered a cardiac arrest and an unsurvivable brain injury, passing away in the arms of her heartbroken parents. Her family, hailing from Mold in Flintshire, has been living with "unbearable" guilt and profound trauma in the wake of the devastating events.

In a candid and deeply moving statement, Alder Hey Children’s Hospital NHS Foundation Trust acknowledged that Eleanor’s "tragic" death "should not have happened." Eleanor’s father, Chaz Aldred, articulated the immense pain and the driving force behind their pursuit of justice: "Not knowing how or why Eleanor died was the key factor, and what kept us going was justice for her. The real victory is making sure what happened to Eleanor doesn’t happen to anyone else. No other family or child will have to go through what we have." He revealed the agonizing uncertainty the family endured, admitting that he and his wife, Rachel, were "fairly certain it was neglectful" but lacked the understanding of the full extent of the failures, feeling "at the mercy of what Alder Hey were telling us." He further elaborated on the arduous journey to acknowledgement, stating, "They said it was breach of duty and not gross neglect, and it took a long time for the trust to admit that." The admission of "gross neglect" by the trust, he shared, was the most difficult hurdle to overcome.

The sequence of events leading to Eleanor’s death began with routine surgery for craniosynostosis on September 29, 2023. While the surgical procedure itself was reported to have gone as planned, a critical error occurred when the breathing tube used during anaesthesia was accidentally removed. This was, however, replaced by the anaesthetist, and the procedure was allowed to continue. During the post-operative recovery period, Eleanor exhibited concerning signs, including a raised heart rate and a need for oxygen. A decision was made to initiate AIRVO, a form of high-flow humidified oxygen therapy. Crucially, this intervention was not documented and was not prescribed in accordance with the trust’s established guidelines, marking another significant departure from standard care protocols.

Following her operation, Eleanor developed a collapsed lung, a direct complication of the surgery. The gravity of this complication was compounded by a further alarming failure: a radiographer failed to flag her abnormal chest X-ray to any member of the ward staff. Adding to the critical delay, the doctor responsible for reviewing the X-ray was unavailable to do so immediately, as she was attending to another child in the Accident and Emergency department. It was in this critical window, before the collapsed lung was identified and treated, that Eleanor suffered a cardiac arrest. The ensuing cardiac arrest led to an unsurvivable brain injury, ultimately resulting in her death.

A comprehensive investigation into Eleanor’s care meticulously detailed 24 distinct failures that culminated in her untimely demise. Among these failures was the repeated inability to correctly calculate Eleanor’s Paediatric Early Warning System (PEWS) score on several occasions. Had her PEWS score been accurately assessed, it would have triggered a much earlier medical review and necessitated an immediate chest X-ray, potentially averting the catastrophic chain of events.

In a poignant statement, Eleanor’s family expressed the profound and enduring pain they have experienced: "Eleanor’s death was preventable and should not have happened. As parents, the guilt is unbearable, even though we know Eleanor was failed by the trust and not by us. We are irreversibly changed as people. We don’t just constantly grieve for her; we grieve for the people we used to be when our daughter was here." Despite the overwhelming grief, the family acknowledged the positive changes the trust has implemented in the wake of Eleanor’s death. They stressed the vital importance of these changes being "used properly, kept under review, and make care safer for other children."

Chaz Aldred further shared that two new post-operative procedures have been introduced at Alder Hey, and they have been named in Eleanor’s honour. He views these implemented changes as Eleanor’s legacy, a source of pride for him and his wife amidst their sorrow. Lynda Reynolds, the family’s solicitor and a partner at Hugh James, described the case as "an unimaginably tragic case." She emphasized the profound betrayal of trust experienced by Eleanor’s parents: "Eleanor’s parents placed their trust in Alder Hey Children’s Hospital to care for their daughter and were let down. For Eleanor’s family, the trust’s acceptance of responsibility and public apology are important, but this follows a long and painful process. We hope that the changes the trust have implemented continue to make care safer for other children." The trust’s admission of responsibility marks a crucial step in a long and arduous journey for Eleanor’s family, a journey defined by grief, the pursuit of truth, and the unwavering hope that her tragic death will serve as a catalyst for lasting improvements in paediatric care. The establishment of the Eleanor Aldred-Owen Paediatric Critical Care Pathway, a direct result of the advocacy and determination of her family, aims to embed the lessons learned from this devastating case, ensuring that no other family has to endure such profound loss due to systemic failures. This pathway includes enhanced protocols for monitoring critically ill children, improved communication between medical teams, and a greater emphasis on timely escalation of concerns. The trust has committed to ongoing review and auditing of these new procedures, underscoring their dedication to learning from this tragedy and fostering a culture of continuous improvement in patient safety. The family’s tireless efforts have not only brought about accountability but have also directly contributed to tangible improvements in the care provided at Alder Hey, ensuring Eleanor’s memory is honoured through a commitment to safeguarding other vulnerable children.