The key facts

  • Alder Hey Children's Hospital NHS Foundation Trust admitted full responsibility for 24 failings in care that led to the death of 21-month-old Eleanor Aldred-Owen on 2 October 2023.
  • The coroner concluded: the death was misadventure aggravated by neglect; an abnormal chest X-ray was not escalated, and the collapsed lung was identified after cardiac arrest.
  • The coroner concluded the death was misadventure contributed to by neglect; the abnormal chest X-ray was not escalated, and the collapsed lung was identified after cardiac arrest.
  • Following the case, the hospital introduced an escalation process for critical X-ray findings and two post-operative procedures named after Eleanor.
  • Following the case, the hospital introduced a process for escalating critical X-ray findings and two post-operative procedures named after Eleanor.

Admission of responsibility after two years of proceedings

Alder Hey Children's Hospital in Liverpool has officially accepted full responsibility for 24 failings in care that led to the death of 21-month-old Eleanor Hazel Aldred-Owen from the town of Mold (Flintshire, Wales). The girl died on 2 October 2023; the coroner concluded that the death resulted from misadventure brought about by neglect. This is reported by BBC Wales, while the admission of responsibility itself has been published on the hospital trust's website.

What happened at the hospital

On 29 September 2023, Eleanor underwent planned surgery for craniosynostosis — a congenital developmental defect of the skull. According to the investigation, the operation went as planned, apart from the accidental removal of the breathing tube during anaesthesia, which the anaesthetist replaced, and the procedure continued. During recovery, the girl had an elevated heart rate and increased oxygen requirement: she was started on high-flow humidified oxygen (AIRVO), which was not documented and was not prescribed in line with the trust's rules. After the operation, she developed a collapsed lung as a consequence of the surgical intervention.

The missed X-ray and 24 failings

The key moment: the radiologist did not inform anyone in the department about the abnormal chest X-ray, and the doctor did not review the image straight away because at that moment she was examining another child in the admissions unit. Cardiac arrest occurred before the collapsed lung was identified and treated, leading to a unsurvivable brain injury. The investigation identified 24 failings in care, including repeated incorrect calculation of the Paediatric Early Warning System score — had it been calculated correctly, the medical review and X-ray would have been carried out significantly earlier.

The family and changes at the hospital

The girl's father, Chaz, told the BBC that the trust had long maintained that this was a 'breach of duty' rather than gross negligence, and that securing the admission of 'gross negligence' was the hardest part. The family stated that Eleanor's death was preventable and noted that the changes introduced after her death must 'be used properly, be kept under constant review and make care safer for other children'. According to the father, Alder Hey has introduced two post-operative procedures named after Eleanor, and the trust reported the creation of a clear escalation process in the radiology department for grossly abnormal and urgent findings. The family's solicitor, Linda Reynolds of the firm Hugh James, described the case as 'unimaginably tragic' and stressed that the admission of responsibility and public apology came as the result of a long and painful process. The trust said that 'the shocking loss of Eleanor has left an indelible mark on everyone' and that the hospital is 'devastated that we let Eleanor and her family down'.

Eleanor Hazel Aldred-Owen lying down and looking upwards. She had dark hair and is wearing a white top with pink and blue unicorns and rainbowsImage source, Family photo
Image caption,

Eleanor Hazel Aldred-Owen was 21 months old when she died at Alder Hey Hospital

Chaz is on the left smiling at the camera, he has short brown hair and a ginger beard/goatee, he has dark glasses on a red t-shirt. Rachel is on the right and kisses Eleanor as she holds her. Rachel has her black hair tied up and has a black t-shirt on. Eleanor looks at the camera. She has short light brown hair and a pink, white and blue top on.Image source, Family photo
Image caption,

Eleanor's parents Rachel and Chaz say they miss their beautiful, much-loved daughter, who brought so much joy into their lives

Rachel, who had dark hair in a bun and rubber duck earrings in her ears, smiling and looking at the camera, with baby Eleanor in her arms and Chaz, who has glasses and a ginger beard, stood beside her.Image source, Family photo
Image caption,

Eleanor's parents Rachel and Chaz say their lives are empty without their little girl

Teddy, a little boy sitting in a hospital bed with a soft toy of Tigger and Winnie the Pooh. He has a medical tube coming out of his nose and wears a white t-shirt with animals on.The back of a police officer's jacketA head and shoulders shot of Richard Hammond. He has dark hair and a goatee and is wearing a grey chequered blazer and blue shirt, with a black lanyard just visible.