The family of 21-month-old Eleanor Aldred-Owen have expressed their devastation at the findings handed down at Liverpool and Wirral Coroners Court, where the Coroner concluded Eleanor’s death was misadventure contributed to by neglect.
Their daughter Eleanor Aldred-Owen died at Alder Hey Hospital in Liverpool on 2 October 2023. The family welcomed the acknowledgement of the failings that contributed to her death, before stressing “none of this changes the fact we have to continue our lives without Eleanor”.
Eleanor had undergone routine surgery for craniosynostosis on 29 September. The surgery was uneventful with the exception of an accidental extubation (removal of the breathing tube used during anaesthetic) towards the end of the surgery.
On the ward, Eleanor’s heart rate continued to be high, and a decision which was undocumented and not prescribed in accordance with Trust guidelines was made to start AIRVO, a type of high flow humidified oxygen.
Eleanor’s heart rate remained high, her respiratory rate was increasing and her parents remained concerned about her breathing. A medical review was undertaken and a chest x-ray and repeated bloods were requested.
A radiographer then failed to flag an 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, which caused an unsurvivable brain injury. Eleanor passed away on 2 October 2023 in her parent’s arms.
The inquest, led by HM Assistant Coroner Helen Rimmer, concluded that Eleanor’s death was a misadventure contributed to by neglect. The internal review by Alder Hey Hospital identified 24 failures in care, and the Trust acknowledged that Eleanor’s death was preventable and apologised to her family.
Eleanor’s parents and wider family are devastated by their loss but have also struggled to accept the way the investigation was undertaken and the family participation in it.
Eleanor’s parents Rachel and Chaz have stated:
“The death of Eleanor and watching her deteriorate has devastated us. She was our beautiful and much-loved daughter and our life is empty and quiet without her. We have found the failings in care identified by the hospital and recognised by the Coroner as unbelievable. We thought Eleanor would be cared for by specialists, instead there were 24 identified lessons to be learned in relation to her post operative care.
“The process of the Trust investigation was not an experience we found helpful and in particular we found the stance taken in preparation for the inquest and in the Trusts Submissions to the Coroner only made this worse.
“We are intensely grateful to the Coroner for her thorough investigation and her conclusion that Eleanor died as a result of numerous gross failures to provide her basic medical care, of course none of this changes the fact we have to continue our lives without Eleanor.”
The family were represented by Lynda Reynolds, Partner and Head of our Inquest Team here at Hugh James.
“The numerous and basic errors in Eleanor’s care are difficult to read and I have the utmost understanding as to why her family are so angry at the sheer number of basic errors that led to Eleanor’s death.
They were at her bedside begging for her to be seen because they were so concerned about her breathing and heart rate. They then witnessed the unimaginable trauma of her being resuscitated.
The tension pneumothorax could have been treated at any point prior to her cardiac arrest and she would have recovered. But it was identified 10 minutes too late, when she had been on the ward for several hours struggling to breathe The absolute tragedy of this inquest is that it is a matter of minutes that would have made the difference.”
