A one-year-old girl tragically died due to gross neglect while in hospital care, a coroner has determined. Eleanor Aldred-Owen was diagnosed with bicoronal craniosynostosis at just 12 weeks old, a condition where the skull bones fuse too early, causing potential pressure on the brain and necessitating surgery.
An inquest in Liverpool on Wednesday heard Eleanor underwent surgery at Alder Hey Children’s Hospital on September 29 last year but suffered complications which were not adequately addressed by the hospital, leading to “missed opportunities” for treatment. The hospital has since issued an apology to Eleanor’s family, expressing their sorrow for the shortcomings in her care and pledging to prevent such tragedies in the future, reports the Mirror.
Assistant Coroner Helen Rimmer told the inquest a tube became dislodged during Eleanor’s surgery, resulting in tachycardia – a heart rate exceeding 100 beats per minute. Despite her parents’ concerns, Eleanor, from Mold in Wales, was moved to recovery after the procedure.
Her parents, Rachel and Chaz Aldred-Owen, observed Eleanor’s breathing was abnormal post-surgery and even captured a video to show to medical staff, as reported by the Liverpool Echo.
The court was informed Eleanor had been making ‘grunting’ noises, a potential sign of an airway issue or severe illness. This was seen as a missed opportunity for doctors to conduct a comprehensive medical review.
While on the mend, Eleanor’s heart rate remained high, fluctuating between 172 and 199bpm, and her lips were pale. A blood gas test was carried out but not reviewed, marking another ‘missed opportunity’ by the medical team.
Despite these warning signs, Eleanor appeared stable apart from her elevated heart rate. Tragically, later that day, Eleanor collapsed and became unresponsive due to her heart rate being ‘higher than what was acceptable’.
She suffered a cardiac arrest and was transferred to intensive care, but sadly passed away on October 2. Ms Rimmer concluded Eleanor’s death was a result of gross neglect due to multiple missed opportunities in her care.
She told the court: “Eleanor was a one-year-old girl with a medical history. On September 29, 2023, Eleanor was admitted to Alder Hey hospital for surgery. Eleanor had no associated problems and was otherwise well. She went to theatre on September 29 which was uneventful except her tube dislodged and was reincubated.
“Eleanor spent time in recovery when she went into tachycardia. She was returned to the ward and her persistent tachycardia was not identified. This being a basic part of medical attention, Eleanor required, and as a result, a timely review [of her condition] was not triggered. [In recovery] Eleanor was heard grunting and Airvo [an oxygen machine] was requested.
“Over a period of several hours Eleanor deteriorated. No basic observations were recorded, this is a fundamental basic care which would have led to a review of her condition. A chest X-ray was performed and found to be grossly abnormal but was not escalated with ward staff. This is basic critical care that should have been undertaken.
“Sadly, at 10.35pm Eleanor collapsed and suffered cardiac arrest. An MRI scan was performed and on October 1 she became aggressively less stable. Eleanor passed away peacefully in the arms of her parents on October 2. There were missed opportunities throughout her care which have as a whole amounted to gross neglect.”
A spokesperson for Alder Hey Children’s Hospital stated: “After the inquest’s conclusion over the tragic death of Eleanor Aldred-Owen finished today, we accept the Coroner’s findings entirely.
“We offer our heartfelt sympathies to Eleanor’s parents and family, and sincerely apologise for the errors that were made in her care. We accept full responsibility for those errors. They should not have happened and we are deeply sorry that they did. We hope that the subsequent investigation by the trust has helped to provide Eleanor’s family with the answers that they need.
“As a trust, we are committed to ensuring that nothing like this happens again. It is really important that we reflect on our failings in Eleanor’s care and that we make appropriate improvements to our systems and processes. The thorough internal investigation that has been carried out has identified a number of remedial actions which have now been implemented.
“This included a specific review of the protocols and plans we have in place which has led to changes being made in areas such as theatre recovery discharge and escalation, prescribing/administering oxygen and our on-call response process. We have also scrutinised our Paediatric Early Warning System (PEWS) and admission criteria for high dependency care and have applied changes that we decided were necessary to make improvements to both. Alongside this, we have provided enhanced training to our teams including blood gas sampling and analysis.
“We know that no words from us will ease the pain being felt by Eleanor’s parents and family. We are heartbroken that we failed them – and failed Eleanor. For that we will be eternally sorry. Our thoughts remain with them during this time.”
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