Alder Hey Hospital Accepts Responsibility for 24 Failures in Toddler’s Death

What changed

Alder Hey Children’s Hospital NHS Foundation Trust has accepted full responsibility for 24 failures linked to the death of Eleanor Hazel Aldred-Owen, who was 21 months old. Eleanor died on 2 October 2023 after routine craniosynostosis surgery; a coroner concluded she died by misadventure, contributed to by neglect.

The failures included:

• An abnormal chest X-ray was not flagged.
• Her paediatric early-warning score was calculated incorrectly several times.
• A collapsed lung was not identified before she suffered cardiac arrest.
• The resulting brain injury was unsurvivable.

Why it matters

This was not one dramatic mistake in isolation. It was a chain of missed warnings around a child who needed closer review after surgery. Eleanor had a raised heart rate and needed oxygen, but the high-flow oxygen treatment was undocumented and not prescribed according to the trust’s guidelines. The X-ray finding then failed to reach the people who needed to act on it.

That matters because hospital safety often depends on small systems working together: observations recorded accurately, abnormal results clearly communicated and concerns reviewed promptly. When those links fail in sequence, a routine procedure can become fatal.

Eleanor’s parents said they had lived with unbearable guilt and trauma, even though the failures were the trust’s and not theirs. The trust has apologised and introduced two post-operative procedures named after Eleanor. Those changes could become a meaningful part of her legacy if they are used properly and kept under review, but the account does not establish whether they have prevented another case.