Alder Hey Children's Hospital has admitted that the death of a toddler could have been prevented after there were "many missed opportunities" to save her life. Eleanor Hazel Aldred-Owen, from Mold in North Wales, died on October 2, 2024, days after undergoing surgery at the hospital.
Missed opportunities in Eleanor's care
Eleanor was born on Tuesday, December 28, 2021, and was diagnosed with bicoronal craniosynostosis at 12 weeks old. The condition meant that as she grew, her brain would not have enough space, leaving her with a one-in-three chance of developmental delay. A specialist team at Alder Hey advised that, due to the type of craniosynostosis Eleanor had, she should undergo surgery.
In a statement issued on its website, the hospital explained that while the surgery was complex, it was a routine procedure within Alder Hey. Eleanor's parents, Charles and Rachel, agreed to the surgery, which took place on September 28, 2023, while the one-year-old's condition was still considered mild.
Following the surgery, Eleanor developed a pneumothorax, commonly referred to as a collapsed lung. Alder Hey explained it was visible on imaging but there were "delays in the imaging being performed and the pneumothorax was not recognised and escalated in time."
Hospital report and inquest findings
The Alder Hey report stated: "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.
The report added: "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."
Following an inquest into her death and a subsequent civil claim, it was found there were 24 failures in the lead up to Eleanor's death. A coroner concluded in December 2024 that Eleanor's death was misadventure contributed to by neglect.
Changes implemented by Alder Hey
In the wake of Eleanor's death, Alder Hey has implemented changes across the hospital, including 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 staff to deliver Martha's rule - a patient safety initiative in the NHS that allows hospital patients, families, carers, and staff to request an urgent, independent clinical review if a person's condition is deteriorating and their concerns are not being heard.
Other changes include the 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, and prescribing, application and staff training in relation to oxygen, including high flow oxygen, to ensure policies are embedded in all clinical areas.
Alder Hey's statement added: "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."
Family's response
Eleanor's family said: "We are glad the Trust has publicly accepted full responsibility for what happened to Eleanor. Eleanor's death was preventable and should not have happened. It remains hard to accept how many opportunities were missed."
They added: "Knowing that a matter of minutes could have changed everything is something we will have to live with for the rest of our lives. As parents, the guilt is unbearable, even though we know Eleanor was failed by the Trust and not by us. We are irreversibly changed as people. We don't just constantly grieve for her; we grieve for the people we used to be when our daughter was here."
The family also said: "We recognise the changes the Trust has implemented following Eleanor's death. What matters most now is that these changes are used properly, kept under review and make care safer for other children. Nothing can change the fact that we have to continue our lives without Eleanor, but we hope her name will be remembered through real improvements in care."
In a tribute shared after the inquest in 2024, they said: "She loved water and bath time more than anything. [She] would get excited when we were running her bath [because] she would know that the milk came next. Bath time was always the same, lots of toys, singing songs, she would splash about until we pulled her out of there with the biggest smile on her face, knowing she'd be wrapped up in a big towel and mummy would sing the bath time song."
A spokesperson for Hugh James, the family's law firm, said: "This is an unimaginably tragic case. Eleanor's parents placed their trust in Alder Hey Children's Hospital to care for their daughter and were let down. For Eleanor's family, the Trust's acceptance of responsibility and public apology are important, but this follows a long and painful process."
The spokesperson added: "Eleanor's parents have spoken with great honesty about the guilt, distress and trauma they continue to carry. They have shown enormous strength and dignity throughout. Their focus has always been on understanding what happened and making sure the lessons are properly learned in Eleanor's memory. We hope that the changes the Trust have implemented continue to make care safer for other children."
