Overview of the Case
A 21‑month‑old girl, Eleanor Hazel Aldred‑Owen, died at Liverpool’s Alder Hey Children’s Hospital NHS Foundation Trust on 2 October 2023, after undergoing routine surgery for craniosynostosis. A coroner concluded that her death was a misadventure, significantly contributed to by neglect. The hospital trust has now formally accepted responsibility for 24 distinct failures in care that culminated in her tragic loss.
The Tragic Timeline of Eleanor’s Final Hours
Eleanor’s operation took place on 29 September 2023. The procedure began without major complication, although an anaesthetic breathing tube was inadvertently removed and promptly replaced, allowing the surgery to continue. In the immediate postoperative period, her heart rate rose and she required supplemental oxygen. Staff decided to start AIRVO, a high‑flow humidified oxygen system, but the intervention was not recorded and was not administered according to the trust’s guidelines.
Following the surgery, Eleanor developed a collapsed lung, a known risk of the operation. An abnormal chest X‑ray was performed, yet the radiographer failed to alert any ward clinician. The on‑call doctor was reviewing another patient in the emergency department and did not examine the image promptly. During this window, Eleanor suffered a cardiac arrest, resulting in an unsurvivable brain injury. She passed away in her parents’ arms.
Key Failures Identified in the Investigation
An exhaustive review uncovered 24 separate lapses. Among them were: an incorrect Paediatric Early Warning System (PEWS) calculation on several occasions, which would have triggered an earlier medical review and the necessary chest imaging; a failure to flag the abnormal X‑ray; and the undocumented use of AIRVO contrary to protocol. The investigation also highlighted missed opportunities to recognise deteriorating vital signs and a lack of clear escalation pathways for critical radiology findings.
The trust’s internal report noted that these oversights collectively created a cascade of events that directly contributed to Eleanor’s death. Each failure, while seemingly minor in isolation, combined to erode the safety net that should have protected her.
Family’s Ongoing Grief and Pursuit of Justice
Eleanor’s parents, Chaz and Rachel, have spoken publicly about the “unbearable” guilt and trauma that have accompanied her loss. Chaz explained that the lack of clarity surrounding the circumstances of her death was a driving force behind their quest for accountability. He described how the trust initially characterised the incident as a breach of duty, later compelled to admit gross neglect—a shift that felt “the hardest thing” for the family.
The couple emphasised that, despite the trust’s recent acknowledgements and the implementation of new safeguards, the personal void left by Eleanor’s absence remains profound. They have also highlighted two post‑operative procedures that have been introduced at Alder Hey and now bear Eleanor’s name, viewing these changes as a tangible legacy that may prevent similar tragedies for other children.
Hospital’s Response and Systemic Changes
Alder Hey Children’s Hospital NHS Foundation Trust issued a statement describing Eleanor’s loss as “shocking” and “permanent”. The organisation expressed deep sorrow for the failures that led to her death and outlined concrete steps taken to improve patient safety. A clear escalation protocol for grossly abnormal and time‑critical radiology findings has been instituted within the imaging department.
The trust also accepted full responsibility for the 24 identified failures, describing them as “profoundly sorry” and committing to continuous review of the new measures. Lynda Reynolds, the family’s solicitor from Hugh James, characterised the case as “an unimaginably tragic case” and stressed that while the trust’s acceptance of responsibility and public apology were important, they followed a “long and painful process”.
Why it Matters
This case underscores the critical importance of robust safety protocols, transparent communication, and diligent monitoring in paediatric healthcare. The 24‑point catalogue of failures reveals how systemic weaknesses can intersect with individual oversights to produce devastating outcomes. By publicly acknowledging responsibility and implementing targeted reforms, Alder Hey not only honours Eleanor’s memory but also seeks to rebuild trust with families who rely on the NHS for the most vulnerable members of society. The ongoing scrutiny of these changes will be essential to ensure they are effectively applied, continually evaluated, and ultimately safeguard future patients from similar tragedies.
