Eleanor Hazel Aldred-Owen was born on 28th December 2021 and died on 2nd October 2023 at Alder Hey Children’s Hospital. Eleanor was the much-loved daughter of Charles and Rachel and the Trust makes this statement in memory of Eleanor, jointly with them.
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 was around 12 weeks old when she was diagnosed with a condition called Bicoronal Craniosynostosis, which meant that as she grew, her brain would not have enough space resulting in a one in three chance of developmental delays of her speech and language, hearing, sight, and learning.
The specialist craniofacial team at Alder Hey advised that due to Eleanor having this particular type of craniosynostosis, surgical intervention for fronto-orbital remodelling of her skull was her only real option. The surgery, although complex, was a routine procedure within Alder Hey, as the regional centre for paediatric craniofacial services. Charles and Rachel agreed to go ahead with the surgery while Eleanor’s condition was still mild and to avoid developmental delay.
Eleanor sadly developed a pneumothorax shortly after surgery. The pneumothorax was visible on imaging but there were delays in the imaging being performed and the pneumothorax was not recognised and escalated in time. There were many missed opportunities by different members of the clinical team at various stages to identify, escalate and treat Eleanor’s deteriorating condition before she suffered a cardiac arrest. These missed opportunities included a failure to escalate grossly abnormal X-ray findings, a matter identified during the inquest and one which has led the Trust to introduce a clear escalation process within the Radiology Department for grossly abnormal and time-critical findings.
Had the pneumothorax been recognised and treated promptly by insertion of a chest drain, Eleanor’s death would have been prevented. The Trust accepts full responsibility for these failures and is profoundly sorry that they resulted in Eleanor’s death.
HM Coroner’s official Record of Inquest provides an objective summary of what happened to Eleanor on the day of her surgery. It has been reproduced below:
Record of Inquest – Eleanor Aldred-Owen (1MB pdf)
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. Many of the actions were implemented very quickly following the Trust’s internal investigations into Eleanor’s clinical journey on the day of her surgery. Some took more time because a hospital-wide reorganisation of our systems relating to deteriorating patients had to be done with progress reported directly to the Trust Board by the Chief Medical Officer and Chief Nursing Officer.
The most important changes are as follows:
• 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 Eleanors 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’s focus on deteriorating patients has continued within the oversight of the Patient Safety Board and is monitored under a number of separate workstreams:
– Hospital Observation Policy
– Introduction National PEWS
– Digital Integration of Observation devices into the electronic patient record (EPR)
– Review of Airvo policy (High Flow Oxygen)
– Martha’s Rule implementation
– Workforce realignment across General Paediatric/HDU
– Education framework for deterioration
– Safety culture.
Most recently, in February 2026 a report was submitted to the Trust Board to update on the full extent of the work undertaken to date to ensure that no case like Eleanor’s happens again.
The report includes progress against the two statistical measures put in place from June 2024, which track the number of patients deteriorating from an inpatient bed admitted to critical care and the number admitted to PICU from HDU. Each month the preventability and predictability framework is applied to unplanned admissions from in-patient wards into HDU and from HDU into PICU. This provides clinical narrative against the data to assess if deteriorations requiring transfer were predictable, preventable or modifiable.
Highlights of progress from the workstreams include:
– The new observation policy has been instituted across the Trust and with the device integration it allows us to monitor compliance across the trust in real time to allow for constant improvement.
– We have adopted the National Paediatric Early Warning Score (PEWS) and are producing data which is allowing us to adapt our escalation plans.
– The policy that supports the use of humidified oxygen and high flow oxygen and the educational package in relation to its prescription/use and escalation have been reviewed and training has been enhanced.
– Martha’s Rule has now been rolled out to all inpatient areas supported by a WhatsApp innovation allowing communication between staff and the Response Team with an educational and promotional package alongside it.
– A Trust wide safety culture programme has been developed and specifically for the deteriorating patient work we have initiated a Deteriorating Patient Learning Forum meeting, which will aim to bring teams together across professional, departmental, and hierarchical boundaries to strengthen teamworking, share understanding and communication during episodes of patient deterioration.
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.