Devastated parents describe how they watched one-year-old die after hospital made 24 ‘unbelievable’ mistakes

The parents of a one-year-old girl who died after ‘gross neglect’ have called the mistakes made at a hospital where she was being cared for ‘unbelievable’. Eleanor Aldred-Owen, from Mold, was diagnosed with bicoronal craniosynostosis at just 12 weeks old.

This condition meant that the sutures, the fibrous tissue joints connecting the bones of the skull, had fused prematurely, preventing normal growth and necessitating surgery to alleviate potential pressure on her brain. An inquest into Eleanor’s death held at Gerard Majella Coroner’s Courthouse in Liverpool on Wednesday (December 18) heard how Eleanor attended Alder Hey Children’s Hospital in Liverpool for surgery on September 29 2023, but complications arose and the hospital missed crucial opportunities to address them.

Alder Hey has since apologised to the family, expressing their heartbreak over failing both the family and Eleanor. They have also pledged to ensure such an incident does not recur.

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Eleanor’s parents Rachel and Chaz have now issued a heartbreaking statement following the inquest saying their lives are “empty and quiet” without their daughter. They said: “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.”

-Credit:Chaz Aldred-Owen

Assistant Coroner Helen Rimmer revealed during the inquest how a tube was dislodged during Eleanor’s surgery, leading to tachycardia (an abnormally fast heart rate exceeding 100 beats per minute). Despite concerns raised by her parents, Eleanor was moved to recovery post-surgery.

Her parents, Rachel and Chaz Aldred-Owen, noticed their daughter’s abnormal breathing following the operation and even recorded a video to show the staff, reports North Wales Live.

Eleanor was also observed “grunting,” a symptom that could indicate an airway issue or a severe illness. The court heard this was a missed chance for a comprehensive medical review by doctors.

While recovering, Eleanor remained in a state of tachycardia with a heart rate ranging from 172 to 199bpm and her lips were described as pale. A blood gas test was conducted but unfortunately, the results were not reviewed, which the court deemed another “missed opportunity” by the medical staff.

Despite these signs, Eleanor appeared stable apart from being tachycardic. Later that day, she collapsed and became unresponsive due to her excessively high heart rate. Join our WhatsApp news community here for the latest breaking news. You will receive updates from us daily.

She suffered a cardiac arrest and was moved to intensive care, but tragically, she passed away on October 2. Rimmer concluded that Eleanor’s death was a result of gross neglect following numerous missed opportunities throughout her care.

Assistant Coroner Helen Rimmer told the inquest that the failings in Eleanor’s care amounted to gross neglect -Credit:Hugh James

She informed the court: “Eleanor was a one year old girl with a medical history. On September 29, 2023, she was admitted to Alder Hey hospital for surgery. Apart from this, Eleanor had no associated problems and was generally healthy. Her surgery on September 29 was uneventful except for her tube becoming dislodged and needing re-incubation.”

The coroner’s report stated: “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.”

The report continued: “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.”

The coroner concluded: “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.” The coroner added: “There were missed opportunities throughout her care which have as a whole amounted to gross neglect.”

Alder Hey Trust confirmed that Eleanor’s death was preventable and have apologised to her family. Lynda Reynolds, the family’s solicitor, working with Hugh James said that Eleanor’s parents were “at her bedside begging for her to be seen” and they then “witnessed the unimaginable trauma of her being resuscitated.”

A spokesperson for Alder Hey Children’s NHS Foundation Trust said: “Following the conclusion today of the inquest into the tragic death of Eleanor Aldred-Owen, the Trust fully accepts the coroner’s findings. We are deeply sorry. 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.”

Image Credits and Reference: https://uk.yahoo.com/news/devastated-parents-describe-watched-one-110700139.html