Eleanor Hazel ALDRED-OWEN · Prevention of Future Deaths report

On 11 October 2023 I commenced an investigation into the death of Eleanor Hazel ALDRED-OWEN aged 1. The investigation concluded at the end of the inquest on 18 December 2024. The conclusion of the inquest was that:

The conclusion of the inquest was that cause of death:

1a. Severe hypoxia ischaemic encephalopathy (with coning)
1b. Cardio respiratory arrest
1c. Right tension pneumothorax

Conclusion:

Misadventure contributed to by neglect.

Eleanor was admitted to Alder Hey Children’s Hospital on 29th September 2023 for elective craniofacial surgery. There was no associated problems or genetic abnormalities, and Eleanor was otherwise well. The procedure for bicoronal synostosis was uneventful except that Eleanor’s tracheal tube dislodged towards the end of the procedure and she required reintubating. Eleanor returned to the ward following her surgery and was seemingly stable apart from being tachycardic. Over a period of several hours, she deteriorated with increased breathing and respiratory distress. At 22:35 hours Eleanor sustained a cardiac arrest and required full resuscitation over the course of 20 minutes until return of spontaneous circulation was achieved. A chest x ray that had been ordered at 22:03 hours and was performed at 22:18 hours was grossly abnormal but this was not raised or concerns escalated with any of the medical or nursing staff on the ward. The x ray was not reviewed until 22:40 hours and revealed a right sided tension pneumothorax, which was decompressed and a drain inserted. There was a period of approximately 30 minutes between the x ray being taken at 22:18 hours and bilateral needle decompression being performed at 22:48 hours, effective resuscitation was unlikely to have occurred until the bilateral needle decompression was performed on Eleanor, this delay in the decompression being performed more likely than not contributed to the subsequent ischaemia suffered by Eleanor. Eleanor was transferred to the paediatric intensive care unit and over the course of the next two days became gradually unwell, a CT scan of her head was obtained which showed catastrophic hypoxic ischaemic change with evidence of coning. Life sustaining measures were then withdrawn and Eleanor sadly died on 2nd October 2023.

1) Evidence was given at the inquest that the standard operating procedure for radiographers did not include provision for radiographers to escalate care and put out an urgent arrest call where there were clear signs of imminent danger to life. It was not known whether this was also the case in other Trusts on a national level.