The death of a North Wales hospital at Alder Hey was “tragic and needless”. Eleanor Hazel Aldred-Owen, from Mold , Flintshire went in for routine surgery for a skull condition at the specialist children’s hospital on Merseyside but tragically died aged just 21 months on October 2, 2023 as a result of multiple failures in her care. Eleanor went into hospital for routine surgery for craniosynostosis at Alder Hey Children’s Hospital NHS Foundation Trust on 29 September 2023. Eleanor, developed a pneumothorax (collapsed lung) as a result of the surgery performed, her parents, Charles and Rachel said. They said: “We watched her struggle to breathe. We raised concerns about her breathing and heart rate, but her deteriorating condition was not recognised.” Don’t let an algorithm select your North Wales news. Ensure our latest news headlines always appear at the top of your Google Search by making us a Preferred Source. Click here to activate or add us as Preferred Source in your Google search settings. A pneumothorax was subsequently identified on a chest x-ray, by a radiologist at Alder Hey. with more than enough time to save Eleanor, but the findings were not appropriately escalated as they should have been. Sadly, Eleanor suffered a cardiac arrest before the pneumothorax was identified and treated. Eleanor’s heart was restarted and she was transferred to paediatric intensive care. Unfortunately, a brain scan identified an unsurvivable brain injury caused by the prolonged cardiac arrest and Eleanor passed away on 2 October 2023 in her parents’ arms. An inquest took place in December 2024, and the coroner concluded Eleanor’s death was misadventure contributed to by neglect. Following the conclusion of the civil claim, the Trust has now issued a public statement acknowledging their role in Eleanor’s death. An internal review by the Trust and the report confirmed there were 24 failures in care which resulted in her death. An Alder Hey spokesperson said: “The Trust has taken full responsibility for the events that led to Eleanor’s tragic and needless death at our hospital. It should not have happened and everyone at Alder Hey is deeply sorry that it did. 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.” Eleanor’s parents, Charles and Rachel, said: “We are glad the Trust has publicly accepted full responsibility for what happened to Eleanor. Eleanor’s death was preventable and should not have happened. “It remains hard to accept how many opportunities were missed. Knowing that a matter of minutes could have changed everything is something we will have to live with for the rest of our lives. “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. “We recognise the changes the Trust has implemented following Eleanor’s death. “What matters most now is that these changes are used properly, kept under review and make care safer for other children. “Nothing can change the fact that we have to continue our lives without Eleanor, but we hope her name will be remembered through real improvements in care. “Eleanor was our beautiful, much-loved daughter. She brought so much joy into our lives. “Her name was Eleanor. We love her. We miss her.” The family’s legal representatives, Hugh James, said: “This is an unimaginably tragic case. Eleanor’s parents placed their trust in Alder Hey Children’s Hospital to care for their daughter and were let down. “For Eleanor’s family, the Trust’s acceptance of responsibility and public apology are important, but this follows a long and painful process. “Eleanor’s parents have spoken with great honesty about the guilt, distress and trauma they continue to carry. “They have shown enormous strength and dignity throughout. Their focus has always been on understanding what happened and making sure the lessons are properly learned in Eleanor’s memory. “We hope that the changes the Trust have implemented continue to make care safer for other children.” The Trust recognises fully that the inquest into Eleanor’s death was incredibly painful for Charles and Rachel and their wider family. Charles and Rachel have subsequently told us that they want us to communicate publicly about the work we have done as a result of Eleanor’s death to prevent any similar event from happening again and to reassure other parents; we have given our commitment to do this. We describe below the steps we have taken since Eleanor’s death to improve our safety systems when a child’s condition deteriorates. A significant re organisation of out of hours senior medical cover both on the wards and in the main HDU. This allows for more timely assessment and management of deteriorating patients and those subspecialty HDU patients being nursed outside of general HDU and also within the main HDU. This has the additional benefit of enabling us to deliver Martha’s rule. Development of a formal standard operating policy (SOP), for escalation and discharge in the theatre recovery area. A clear escalation process within Radiology for when an X-ray detects grossly abnormal and/or time critical findings by the radiography team. This is a major change in custom and practice at Alder Hey that had, up to Eleanor’s time, been of long standing. Prescribing, application and staff training in relation to oxygen, including high flow oxygen, to ensure that policies are embedded in all clinical areas, are fully understood and adhered to. In addition, what happened to Eleanor has informed a broad range of workflows that form part of the hospital’s obligation to improve the way in which we deliver care for patients. This includes reviews of hospital operating policies and procedures in the following areas: Training needs for staff in relation to blood gas sampling, analysis and interpretation. The consistent recording of nursing and/or parental concerns as part of the PEWS score, as per national policy together with appropriate staff training. Successful pilot of Martha’s Rule, enabling parents to escalate a concern directly with the Response Team. Admission criteria and the expected level of care provided to patients admitted to Ward 4A Neurosurgical HDU. Response Team attendance at resident doctor induction to give an overview of service provision, roles and escalation routes. Clarification of all appropriate staff who can order urgent diagnostic tests, including the Response Team. All areas of resuscitation including policies, procedures and training/education are in line with expected and recommended national standards for all relevant staff groups including doctors on rotation. A clear hospital-wide guide on clinical deterioration to ensure standardisation and consistency. The Trust remains fully committed to this work on a long-term basis – we do so in memory of Eleanor, she will never be forgotten. You can read the Trust’s statement in full here. 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Original source: gb