A one-year-old girl from Mold tragically passed away due to gross neglect by Alder Hey Children’s Hospital, a coroner’s ruling revealed. Eleanor Aldred-Owen was diagnosed with bicoronal craniosynostosis at just 12 weeks old, leading to premature fusion of the skull bones’ fibrous tissue joints. To alleviate potential brain pressure, surgery was necessary. During an inquest at Gerard Majella Coroner’s Courthouse in Liverpool, it was disclosed that Eleanor faced complications during her surgery on September 29 last year at Alder Hey, where crucial opportunities to address these issues were missed. The hospital has since issued an apology to the family, acknowledging the heartbreaking failure in Eleanor’s care and promising measures to prevent such incidents in the future.
Assistant Coroner Helen Rimmer detailed during the inquest how a dislodged tube during Eleanor’s surgery led 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. Observing abnormal breathing and grunting in Eleanor post-operation, her parents notified the staff, but unfortunately, these symptoms were not thoroughly evaluated by the medical team. Eleanor’s heart rate remained high, ranging from 172 to 199bpm, and indicators like pale lips were not addressed promptly. Although a blood gas test was performed, the results were overlooked, marking another missed opportunity in Eleanor’s care.
Eleanor’s condition continued to deteriorate despite appearing stable apart from the tachycardia. Tragically, on the same day, she collapsed and became unresponsive due to the escalated heart rate, ultimately leading to a cardiac arrest. Despite efforts to move her to intensive care, Eleanor passed away on October 2. The coroner unequivocally stated that Eleanor’s demise was a result of gross neglect, attributing it to numerous missed opportunities throughout her medical care process. The coroner outlined the sequence of events that underscored the extent of the neglect in Eleanor’s case, emphasising the critical oversight and lack of timely interventions that could have altered the outcome.
In response to the coroner’s findings, a spokesperson for Alder Hey Children’s NHS Foundation Trust expressed deep regret over the errors made in Eleanor’s care, extending heartfelt sympathies to her family and acknowledging full responsibility for the lapses. The hospital pledged to learn from the incident and implement necessary improvements in their protocols and response mechanisms to prevent such tragedies from recurring. The Trust’s detailed examination following Eleanor’s death led to the identification of several areas requiring remedial actions, leading to changes in various aspects of care delivery, including theatre recovery discharge procedures, oxygen administration protocols, and emergency response processes.
The thorough internal investigation also led to enhanced training for the medical teams, focusing on areas like blood gas sampling and analysis to ensure better patient outcomes. The Trust’s commitment to introspection and improvement was reiterated, acknowledging the pain felt by Eleanor’s family and expressing profound regret for failing both them and Eleanor. As the Trust reflects on the shortcomings in Eleanor’s care, they remain dedicated to implementing lasting changes to enhance patient safety and quality of care provision. The lessons learned from Eleanor’s tragic case are seen as crucial in shaping a more robust and responsive healthcare system at Alder Hey Children’s Hospital.
This heartbreaking incident serves as a sobering reminder of the profound impact of medical negligence and the critical importance of stringent protocols, vigilant monitoring, and prompt interventions in healthcare settings to safeguard patient well-being and prevent avoidable tragedies. Eleanor’s story underscores the profound implications of missed opportunities and serves as a poignant call to action for healthcare providers to prioritise patient safety and quality care above all else. May Eleanor’s memory inspire lasting changes and improvements in the healthcare system to prevent similar tragedies in the future.