Alder Hey Children's Hospital NHS Foundation Trust has accepted full responsibility for 24 failures in care that resulted in the death of 21-month-old Eleanor Hazel Aldred-Owen, who died on 2 October 2023 after routine surgery for craniosynostosis, a birth defect affecting the skull. A coroner concluded she died as a result of misadventure, contributed to by neglect.
Eleanor, from Mold, Flintshire, had surgery on 29 September 2023. During recovery, she had a raised heart rate and needed oxygen, and a decision was made to start AIRVO, a type of high-flow humidified oxygen, which was undocumented and not prescribed in line with the trust's guidelines. After the operation, she developed a collapsed lung as a result of surgery, but a radiographer failed to flag her abnormal chest X-ray to anyone on the ward, and the doctor did not review it immediately as she was in A&E reviewing another child. Eleanor suffered a cardiac arrest and unsurvivable brain injury before the collapsed lung was identified and treated.
An investigation found 24 failures in care, including failure to correctly calculate her Paediatric Early Warning System score on several occasions, which would have led to a much earlier medical review and chest X-ray.
In a statement, Eleanor's parents, Chaz and Rachel, said: "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."
Eleanor's father, Chaz, said: "Not knowing how or why Eleanor died was the key factors 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 added that both he and his wife were "fairly certain it was neglectful" but that the trust said it was a breach of duty and not gross neglect. He described the trust "being compelled to admit gross neglect" as the hardest thing.
The trust said: "The shocking loss of Eleanor has left a permanent mark on us all. We are heartbroken that we failed Eleanor and her family and we want to make sure that such a tragedy does not happen again." It added that the missed opportunities, including a failure to escalate grossly abnormal X-ray findings, had led it to introduce a clear escalation process within radiology for grossly abnormal and time-critical findings. The trust said it was profoundly sorry that its failures resulted in Eleanor's death.
Chaz said he does not want Eleanor to be forgotten: "She was happy, strong and funny. She loved music and water. She loved us and we loved her."
Lynda Reynolds, the family's solicitor at Hugh James, called it "an unimaginably tragic case" and said the trust's acceptance of responsibility and public apology were important but followed a long and painful process.
The family acknowledged changes the trust has implemented since Eleanor's death, but said these must be "used properly, kept under review and make care safer for other children". Chaz said two post-operative procedures had been brought in at Alder Hey and named after Eleanor.
Analysis
Why This Matters
- The trust’s admission of full responsibility for 24 failures highlights systemic weaknesses in post-operative monitoring and escalation of abnormal results in paediatric care.
- Eleanor's parents have pushed for changes that could prevent similar deaths; two procedures named after her have been introduced at Alder Hey.
- The case underscores the emotional toll on families when medical trust is breached, and the importance of transparent investigations and public apologies.
Background
Alder Hey Children's Hospital NHS Foundation Trust in Liverpool is one of Europe’s largest children's hospitals. Craniosynostosis is a birth defect where the bones in a baby’s skull join too early, often requiring surgery. The trust has faced previous criticism over patient safety, but this case is the first where it has accepted full responsibility for gross neglect leading to a child’s death.
Key Perspectives
- Eleanor's family (Chaz and Rachel Aldred-Owen): Say the death was preventable, and that the guilt is unbearable though they know the trust failed Eleanor. They want the changes implemented to be properly used and kept under review so no other family suffers.
- Alder Hey Children's Hospital NHS Foundation Trust: Says Eleanor's loss “has left a permanent mark on us all” and that it is “heartbroken” it failed her family. It has accepted full responsibility and introduced a clear escalation process for abnormal X-ray findings and two post-operative procedures named after Eleanor.
- Lynda Reynolds (family solicitor): Describes it as “an unimaginably tragic case” and notes the trust’s acceptance of responsibility and apology were important but came after a long and painful process.
What to Watch
- Whether the trust’s new escalation process for radiology and named procedures are adopted by other NHS hospitals.
- Any further independent review or regulatory action from the Care Quality Commission or NHS England into Alder Hey’s paediatric surgery protocols.
- The family’s ongoing campaign or potential calls for a public inquiry into the case.
Checked
12 claims in this story checked against 1 source: 12 supported.
Show each claim
- SupportedAlder Hey accepted responsibility for 24 failures in care that resulted in the toddler’s death.BBC Wales: “Alder Hey Children's Hospital NHS Foundation Trust has accepted full responsibility for 24 failures that led to the death of a 21-month-old.”
- SupportedEleanor died at Alder Hey after routine surgery for craniosynostosis.BBC Wales: “Eleanor Hazel Aldred-Owen died at Liverpool's Alder Hey Hospital on 2 October 2023 [...] She had routine surgery for craniosynostosis”
- SupportedEleanor’s abnormal chest X-ray was not flagged.BBC Wales: “an abnormal chest X-ray was not flagged.”
- SupportedEleanor was 21 months old when she died.BBC Wales: “Eleanor Hazel Aldred-Owen died at Liverpool's Alder Hey Hospital on 2 October 2023”
- SupportedA coroner concluded Eleanor died as a result of misadventure, contributed to by neglect.BBC Wales: “a coroner concluded she died as a result of misadventure, contributed to by neglect.”
- SupportedEleanor’s surgery was on 29 September 2023.BBC Wales: “Eleanor had routine surgery for craniosynostosis on 29 September 2023”
- SupportedEleanor developed a collapsed lung as a result of surgery.BBC Wales: “After her operation, Eleanor developed a collapsed lung as a result of surgery.”
- SupportedA radiographer failed to flag Eleanor’s abnormal chest X-ray to anyone on the ward.BBC Wales: “A radiographer failed to flag her abnormal chest X-ray to anyone on the ward”
- SupportedThe doctor did not review the X-ray immediately because she was in A&E reviewing another child.BBC Wales: “the doctor did not review it immediately because she was in A&E reviewing another child.”
- SupportedEleanor’s parents said her death was preventable and should not have happened.BBC Wales: “In a statement, her family said: "Eleanor's death was preventable and should not have happened."”
- SupportedChaz said, “Not knowing how or why Eleanor died was the key factors and what kept us going was justice for her.”BBC Wales: “Eleanor's dad Chaz said: "Not knowing how or why Eleanor died was the key factors and what kept us going was justice for her.”
- SupportedChaz said two post-operative procedures had been brought in at Alder Hey and named after Eleanor.BBC Wales: “Chaz said two post-operative procedures had been brought in to Alder Hey and named after Eleanor”