24 Care Failures Detailed in Hospital Trust's Apology Over Mold Toddler's Death

Liverpool's Alder Hey Children's Hospital NHS Foundation Trust has taken responsibility for 24 failures in care that led to the death of Eleanor Hazel Aldred-Owen, a 21-month-old girl from Mold, Flintshire. Eleanor died at the hospital on 2 October 2023. A coroner later concluded she died as a result of misadventure, contributed to by neglect.

Eleanor was admitted for routine surgery for craniosynostosis, a birth defect affecting the skull, on 29 September 2023. The procedure went as planned, save for the accidental removal of the breathing tube used during anaesthesia, which the anaesthetist replaced before continuing. During recovery, she developed a raised heart rate and needed oxygen. A decision to begin AIRVO, a form of high-flow humidified oxygen, was undocumented and not prescribed in line with the trust's guidelines.

After the operation, Eleanor developed a collapsed lung. A radiographer did not flag her abnormal chest X-ray to anyone on the ward, and the reviewing doctor did not assess it immediately because she was in A&E with another child. Eleanor went into cardiac arrest before the collapsed lung was identified and treated, causing an unsurvivable brain injury. She died in her parents' arms.

An investigation identified 24 failures in care that resulted in her death. Among them was a failure to correctly calculate her Paediatric Early Warning System score on several occasions, a step that would have prompted an earlier medical review and chest X-ray. The trust said the missed opportunities, including the failure to escalate grossly abnormal X-ray findings, led it to introduce a clear escalation process within the radiology department for grossly abnormal and time-critical findings. The trust accepted full responsibility for these failures and said it was profoundly sorry they resulted in Eleanor's death.

Her parents, Chaz and Rachel Aldred-Owen, said they have carried guilt and trauma since Eleanor's death. Chaz said he and his wife were 'fairly certain it was neglectful' but did not realize the extent, and that they were 'at the mercy of what Alder Hey were telling us.' He said the trust 'being compelled to admit gross neglect' was the hardest part of the process. In a statement, the family said Eleanor's death was preventable and should not have happened, and that as parents the guilt is unbearable even though they know Eleanor was failed by the trust and not by them.

Chaz said two post-operative procedures have been brought in at Alder Hey and named after Eleanor. He said the changes the hospital put in place were Eleanor's legacy and something he and his wife could be proud of. He said he does not want Eleanor to be forgotten and wants her remembered for the person she was, not how she died. 'She was happy, strong and funny. She loved music and water. She loved us and we loved her,' he said.

Lynda Reynolds, the family's solicitor and partner at Hugh James, called it 'an unimaginably tragic case.' She said Eleanor's parents placed their trust in Alder Hey Children's Hospital to care for their daughter and were let down, and that for the family the trust's acceptance of responsibility and public apology are important, but follow a long and painful process.

Alder Hey Children's NHS Foundation Trust said the shocking loss of Eleanor has left a permanent mark on its staff, and that it is heartbroken it failed Eleanor and her family. The trust said it wants to make sure such a tragedy does not happen again.