Alder Hey admits full responsibility for 24 care failures before toddler Eleanor Aldred-Owen's death

Alder Hey Children's Hospital in Liverpool has taken full responsibility for 24 failures in care that led to the death of a 21-month-old girl.

Eleanor Hazel Aldred-Owen, from Mold, Flintshire, died at the hospital on 2 October 2023. A coroner concluded she died as a result of misadventure, contributed to by neglect.

The trust's statement is blunt: it "has taken full responsibility for the events that led to Eleanor's tragic and needless death." It added: "It should not have happened and everyone at Alder Hey is deeply sorry that it did."

What happened to Eleanor

Eleanor was diagnosed at about 12 weeks old with bicoronal craniosynostosis, a condition in which skull bones fuse too early and restrict room for the growing brain. Her specialist team advised surgery. Her parents, Chaz and Rachel, agreed while her condition was still mild.

The operation took place in late September 2023. The trust describes it as complex but routine for its craniofacial team. It went as planned, apart from the accidental removal of her breathing tube during anaesthesia. The anaesthetist replaced it and the procedure continued.

In recovery, Eleanor had a raised heart rate and needed oxygen. Staff started AIRVO, a form of high-flow humidified oxygen. That decision was undocumented and not prescribed in line with the trust's own guidelines.

She then developed a pneumothorax, a collapsed lung, as a result of the surgery.

The missed X-ray

The collapsed lung was visible on imaging. The trust says there were delays in the imaging being done, and the condition was not recognised and escalated in time.

A radiographer did not flag her abnormal chest X-ray to anyone on the ward. The doctor did not review it immediately because she was in A&E with another child.

Eleanor went into cardiac arrest before the collapsed lung was identified and treated. The result was an unsurvivable brain injury. She died in her parents' arms.

Among the 24 failures was the repeated miscalculation of her Paediatric Early Warning System score. A correct score would have triggered a much earlier medical review and chest X-ray.

The trust acknowledged "many missed opportunities by different members of the clinical team" to identify, escalate and treat her deteriorating condition. It also conceded that had the pneumothorax been recognised and treated promptly with a chest drain, her death would have been prevented.

The family's account

The family, through their law firm Hugh James, said: "We watched her struggle to breathe. We raised concerns about her breathing and heart rate, but her deteriorating condition was not recognised, and she was not seen and treated with the urgency she needed."

Chaz Aldred-Owen said he and Rachel were "fairly certain it was neglectful" but did not grasp the extent of it. They were, he said, "at the mercy of what Alder Hey were telling us."

He said the trust initially described what happened as a breach of duty rather than gross neglect. "They said it was breach of duty and not gross neglect and it took a long time for the trust to admit that." The hardest part, he said, was the trust "being compelled to admit gross neglect."

The trust has not publicly responded to that characterisation of its earlier position. Its current statement says it is "heartbroken that we failed Eleanor and her family" and wants to ensure "such a tragedy does not happen again."

The family's own statement says: "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."

What the trust says it has changed

The one concrete fix the trust has described is in radiology. Following the failure to escalate grossly abnormal X-ray findings, which came to light at the inquest, it has introduced a clear escalation process for grossly abnormal and time-critical findings.

That addresses one link in a chain of 24. The trust has not said in its published statement how it has dealt with the other failures, including the miscalculated early warning scores and the undocumented oxygen decision.

Chaz Aldred-Owen has said the family's goal is that no other family goes through this. "The real victory is making sure what happened to Eleanor doesn't happen to anyone else," he said.

It remains unclear whether the trust will detail changes to early warning scoring, post-operative monitoring and prescribing practice, which are the failures a ward-level check should catch.