Alder Hey Children’s Hospital NHS Foundation Trust has accepted full responsibility for multiple failures in care that resulted in the death of Eleanor Hazel Aldred-Owen on 2 October 2023. The child from Mold, Flintshire, was 21 months old when she died following routine surgery for craniosynostosis, a birth defect affecting the skull. A coroner concluded that Eleanor died as a result of misadventure, contributed to by neglect.
During Eleanor’s recovery period after surgery on 29 September 2023, several critical oversights occurred. Medical staff initiated high-flow humidified oxygen support that was undocumented and not prescribed according to hospital guidelines. Eleanor subsequently developed a collapsed lung as a complication of the surgery. A radiographer failed to alert ward staff to abnormal findings on Eleanor’s chest X-ray, and the attending doctor did not immediately review the imaging because she was attending to another patient in the accident and emergency department. Before the collapsed lung could be identified and treated, Eleanor suffered cardiac arrest, which resulted in unsurvivable brain injury.
An investigation identified 24 distinct failures in care contributing to Eleanor’s death. These included inadequate calculation of her Paediatric Early Warning System score on multiple occasions, which would have prompted an earlier medical review and X-ray examination. The hospital trust stated that the missed opportunities, particularly the failure to escalate grossly abnormal radiological findings, prompted implementation of new escalation procedures within the radiology department for time-critical findings.
Eleanor’s parents, Chaz and Rachel, described the experience as leaving them with unbearable guilt and trauma despite understanding their daughter was failed by the hospital rather than by them. The family noted that two post-operative procedures have been established at Alder Hey in Eleanor’s name. Both the hospital and the family’s legal representatives acknowledged that the trust’s acceptance of responsibility and implementation of safety improvements represent Eleanor’s legacy and provide some assurance that similar incidents may be prevented in future patient care.
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