One-year-old died after hospital made 24 errors
Family photoA hospital has apologised for 24 failures in care which led to the death of a toddler.
Eleanor Hazel Aldred-Owen was 21 months old when she died at Alder Hey Hospital in Liverpool on 2 October 2023.
A coroner found Eleanor, from Mold, Flintshire, died as a result of misadventure, contributed to by neglect at an inquest conclusion on Wednesday.
The health board apologised for "the errors that were made in her care".
Her parents, Rachel and Chaz, said their lives were "empty and quiet without her".
Eleanor had undergone routine surgery for craniosynostosis - a birth defect affecting the skull - on 29 September that year.
The surgery was uneventful, apart from the accidental removal of the breathing tube used during anaesthetic, which was replaced by the anaesthetist and the procedure continued.
During recovery, she had a raised heart rate and needed oxygen and a decision was made to start AIRVO, a type of high flow humidified oxygen, which was undocumented and not prescribed in accordance with trust's guidelines.
A radiographer then failed to flag an abnormal chest X-ray to anyone on the ward and the doctor did not review it immediately as she was in A&E reviewing another child.
Eleanor had a cardiac arrest, which caused an unsurvivable brain injury and she died in her parents' arms.
An investigation found there were 24 failures in care which resulted in the death of Eleanor, including failure to correctly calculate her Paediatric Early Warning Scoring Tool (PEWS) score on several occasions which would have led to a much earlier medical review and chest X-ray.
In a statement, her parents said they were "devastated", adding: "We have found the failings in care identified by the hospital and recognised by the coroner as unbelievable."
"The process of the trust investigation was not an experience we found helpful and in particular we found the stance taken in preparation for the inquest and in the trusts submissions to the coroner only made this worse."
They said they were grateful for the coroner's conclusion that Eleanor died "as a result of numerous gross failures to provide her basic medical care" but said "none of this changes the fact we have to continue our lives without Eleanor".
Family photoLynda Reynolds, the family's solicitor and partner at Hugh James, said it was "minutes that would have made the difference".
"I have the utmost understanding as to why her family are so angry at the sheer number of basic errors that led to Eleanor's death ," she said.
"They were at her bedside begging for her to be seen because they were so concerned about her breathing and heart rate. They then witnessed the unimaginable trauma of her being resuscitated."
Following the inquest conclusion, Alder Hey Children's NHS Foundation Trust said it "accepted full responsibility" for its errors.
"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."
It added it was "committed to ensuring that nothing like this happens again" and "remedial actions" had been implemented including scrutiny of workflow and additional staff training.
- This article has been updated, as legal firm Hugh James previously stated there were 25 failures of care, and later amended this to 24.