A one-year-old girl died as a result of gross neglect by Alder Hey, a coroner has ruled. Eleanor Aldred-Owen, from Mold, was diagnosed with bicoronal craniosynostosis when she was 12 weeks old.
Her diagnosis meant the sutures, the fibrous tissue joints that connect the bones of the skull, had fused too early to allow for normal growth and she needed surgery to reduce the risk of pressure on her brain.
An inquest into Eleanor's death at Gerard Majella Coroner's Courthouse in Liverpool on Wednesday, December 18, heard how on September 29, last year, Eleanor attended Alder Hey Children's Hospital for surgery, however she suffered complications and the hospital 'missed opportunities' to treat them.
Alder Hey has apologised to the family and says it's 'heartbroken' that it failed them and failed Eleanor. It has also said it's committed to ensuring that nothing like this happens again.
Assistant Coroner Helen Rimmer told the inquest on Wednesday how a tube was dislodged during Eleanor's bicoronal craniosynostosis surgery and she went into tachycardia (a very fast heart rate over 100 beats per minute) as a result. Eleanor was transferred to recovery following the operation, despite concerns being raised by her parents to hospital staff.
Her parents, Rachel and Chaz Aldred-Owen, had noticed their daughter's breathing was not 'normal' following the surgery and took a video to show staff. Eleanor was also heard 'grunting,' which can be a symptom of an airway problem or a life threatening illness. The court heard how this was a missed opportunity for a full medical review by doctors.
When in recovery, Eleanor stayed in a state of tachycardia with a heart rate of 172 to 199bpm and her lip colour was described as pale. A blood gas test was taken, although the tests failed to be reviewed which was ruled another 'missed opportunity' by staff. Although, Eleanor was seemingly stable apart from being tachycardic.
Later that day, Eleanor collapsed and became unresponsive as a result of her heart rate being 'higher than what was acceptable.' She suffered a cardiac arrest and was transferred to intensive care, but sadly this led to her death on October 2.
Ms Rimmer concluded Eleanor had died as a result of gross neglect following missed opportunities throughout her care.
She told the court: "Eleanor was a one-year-old girl with a medical history. On September 29, 2023, Eleanor was admitted to Alder Hey hospital for surgery. Eleanor had no associated problems and was otherwise well. She went to theatre on September 29 which was uneventful except her tube dislodged and was reincubated.
"Eleanor spent time in recovery when she went into tachycardia. She was returned to the ward and her persistent tachycardia was not identified. This being a basic part of medical attention Eleanor required and as a result a timely review [of her condition] was not triggered. [In recovery] Eleanor was heard grunting and Airvo [an oxygen machine] was requested.
"Over a period of several hours Eleanor deteriorated. No basic observations were recorded, this is a fundamental basic care which would have led to a review of her condition. A chest X-ray was performed and found to be grossly abnormal but was not e...
Her diagnosis meant the sutures, the fibrous tissue joints that connect the bones of the skull, had fused too early to allow for normal growth and she needed surgery to reduce the risk of pressure on her brain.
An inquest into Eleanor's death at Gerard Majella Coroner's Courthouse in Liverpool on Wednesday, December 18, heard how on September 29, last year, Eleanor attended Alder Hey Children's Hospital for surgery, however she suffered complications and the hospital 'missed opportunities' to treat them.
Alder Hey has apologised to the family and says it's 'heartbroken' that it failed them and failed Eleanor. It has also said it's committed to ensuring that nothing like this happens again.
Assistant Coroner Helen Rimmer told the inquest on Wednesday how a tube was dislodged during Eleanor's bicoronal craniosynostosis surgery and she went into tachycardia (a very fast heart rate over 100 beats per minute) as a result. Eleanor was transferred to recovery following the operation, despite concerns being raised by her parents to hospital staff.
Her parents, Rachel and Chaz Aldred-Owen, had noticed their daughter's breathing was not 'normal' following the surgery and took a video to show staff. Eleanor was also heard 'grunting,' which can be a symptom of an airway problem or a life threatening illness. The court heard how this was a missed opportunity for a full medical review by doctors.
When in recovery, Eleanor stayed in a state of tachycardia with a heart rate of 172 to 199bpm and her lip colour was described as pale. A blood gas test was taken, although the tests failed to be reviewed which was ruled another 'missed opportunity' by staff. Although, Eleanor was seemingly stable apart from being tachycardic.
Later that day, Eleanor collapsed and became unresponsive as a result of her heart rate being 'higher than what was acceptable.' She suffered a cardiac arrest and was transferred to intensive care, but sadly this led to her death on October 2.
Ms Rimmer concluded Eleanor had died as a result of gross neglect following missed opportunities throughout her care.
She told the court: "Eleanor was a one-year-old girl with a medical history. On September 29, 2023, Eleanor was admitted to Alder Hey hospital for surgery. Eleanor had no associated problems and was otherwise well. She went to theatre on September 29 which was uneventful except her tube dislodged and was reincubated.
"Eleanor spent time in recovery when she went into tachycardia. She was returned to the ward and her persistent tachycardia was not identified. This being a basic part of medical attention Eleanor required and as a result a timely review [of her condition] was not triggered. [In recovery] Eleanor was heard grunting and Airvo [an oxygen machine] was requested.
"Over a period of several hours Eleanor deteriorated. No basic observations were recorded, this is a fundamental basic care which would have led to a review of her condition. A chest X-ray was performed and found to be grossly abnormal but was not e...
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Daily Post (Digital) - 1 Issue, December 19, 2024