3 days Ago By [email protected] (Megan Banner)
Alder Hey says it accepts the coroner's findings and has apologised to the family A one-year-old girl died as a result of gross neglect by Alder Hey , a coroner has ruled. Eleanor Aldred-Owen, from Mold in Wales, was diagnosed with bicoronal craniosynostosis when she was 12 weeks old. Her diagnosis meant the sutures, the fibrous tissue joints that connect the bones of the skull, had fused too early to allow for normal growth and she needed surgery to reduce the risk of pressure on her brain.
An inquest into Eleanor’s death at Gerard Majella Coroner’s Court house in Liverpool on Wednesday (December 18) heard how on September 29, last year, Eleanor attended Alder Hey Children’s Hospital for surgery, however she suffered complications and the hospital “missed opportunities” to treat them. Alder Hey has apologised to the family and says it’s “heartbroken” that it failed them and failed Eleanor. It has also said it's committed to ensuring that nothing like this happens again.
Assistant Coroner Helen Rimmer told the inquest on Wednesday how a tube was dislodged during Eleanor's bicoronal craniosynostosis surgery and she went into tachycardia (a very fast heart rate over 100 beats per minute) as a result. Eleanor was transferred to recovery following the operation, despite concerns being raised by her parents to hospital staff. Her parents, Rachel and Chaz Aldred-Owen, had noticed their daughter’s breathing was not “normal” following the surgery and took a video to show staff.
Eleanor was also heard “grunting,” which can be a symptom of an airway problem or a life threatening illness. The court heard how this was a missed opportunity for a full medical review by doctors. When in recovery Eleanor stayed in a state of tachycardia with a heart rate of 172 to 199bpm and her lip colour was described as pale.
A blood gas test was taken, although the tests failed to be reviewed which was ruled another 'missed opportunity' by staff. Although, Eleanor was seemingly stable apart from being tachycardic. Later that day, Eleanor collapsed and became unresponsive as a result of her heart rate being "higher than what was acceptable.
" She suffered a cardiac arrest and was transferred to intensive care, but sadly this led to her death on October 2. Ms Rimmer concluded Eleanor had died as a result of gross neglect following missed opportunities throughout 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 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 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.".
