Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0695, written 18 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Dec 2024 |
|---|---|
| Reference | 2024-0695 |
| Deceased | Eleanor Aldred-Owen |
| Coroner | Helen Rimmer |
| Coroner area | Liverpool and Wirral |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS England 2 Chief Coroner 1 CORONER I am Helen RIMMER, Assistant Coroner for the coroner area of Liverpool and Wirral 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST 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: Official 1a. Severe hypoxia ischaemic encephalopathy (with coning) 1b. Cardio respiratory arrest 1c. Right tension pneumothorax Conclusion: Misadventure contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH 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 unstable, a CT Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by February 12, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION Official 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Eleanor’s family I have also sent it to Local Children’s Safeguarding Board Alder Hey NHS Foundation Trust Chief Coroner who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the Regulation 28 – After Inquest Document Template Updated 30/07/2021 release or the publication of your response by the Chief Coroner. 9 Dated: 18/12/2024 Helen RIMMER Assistant Coroner for Liverpool and Wirral Official Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ms Helen Rimmer
HM Assistant Coroner
Liverpool and Wrral
Gerard Majella Courthouse
Boundary Street
Liverpool
L5 2QD
Primary Care Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
11 February 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Eleanor Hazel Aldred-
Owen who died on 2 October 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18
December 2024 concerning the death of Eleanor Hazel Aldred-Owen on 2 October
2023. In advance of responding to the specific concerns raised in your Report, I would
like to express my deep condolences to Eleanor’s family and loved ones. NHS
England are keen to assure the family and the Coroner that the concerns raised about
Eleanor’s care have been listened to and reflected upon.
Your Report raises concerns about the Standard Operating Procedure (SOP) for
radiographers, and whether this includes provision for radiographers to escalate care
and put out an urgent arrest call when there are clear signs of imminent danger to life.
Diagnostic radiographers are registered professionals under the Health and Care
Professions Council (HCPC). Under the HCPC standards, it is expected that all
registered diagnostic radiographers will be able to:
• distinguish between normal and abnormal appearances on images (standard
12.16)
• appraise image information for clinical manifestations and technical accuracy,
and take further action as required (standard 13.17)
• distinguish disease trauma and urgent and unexpected findings as they
manifest on diagnostic images, and take direct and timely action to assist the
referrer (standard 13.40)
In Eleanor’s case, the radiographer would have been expected to recognise the clinical
urgency shown on the X-ray image and immediately alert the referring doctor, or in the
absence of the referring doctor, the medical or nursing staff on the ward of this critical
finding. This expectation is in line with the standards of proficiency for diagnostic
radiographers.
In October 2022, the Academy of Medical Royal Colleges published the Alerts and
notification of imaging reports recommendations which included the expectation that
in time critical events, the radiologist or the diagnostic radiographer may notify the
referrer verbally before the examination is formally reported. The recommendation
includes that this verbal notification should be recorded in the patient record, radiology
information system or on the radiology report.
The Royal College of Radiologists’ Quality Standard for Imaging (QSI) supports
improving standards of imaging services. It is expected that all providers of imaging
services will work towards this QSI, or equivalent quality standard, to ensure their
services are managed effectively and are safe for all users. In the QSI, all imaging
services that work under this quality standard are required to have protocols in place
to manage unexpected diagnoses and indications of potential medical emergencies.
To ensure all radiographers are aware of their responsibilities under the HCPC
standards of proficiency, national communication is shared through the professional
body for diagnostic radiographers – The Society of Radiographers. In addition, NHS
England will share the link to the HCPC proficiency standards for radiographers on the
NHS Futures internet pages, which is a collaboration platform available to anyone
working in or for health and social care. This will support dissemination and remind all
diagnostic radiographers of their responsibilities in clinical practice as state registered
healthcare professionals.
NHS England’s North West regional colleagues have also engaged with NHS
Cheshire and Merseyside ICB on the concerns raised. We are advised that Alder Hey
Children’s NHS Foundation Trust had already amended their SOP to address the
learning required from this particular case, and they presented this evidence during
the inquest. They are disseminating this change through all of their quality and/or
contract meetings with relevant providers and to their Patient Safety Specialist
Community of Practice in February 2025 to support further discussion and awareness.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Eleanor, are shared across the NHS at both a national and regional level and helps
us to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
, MBBS, DRCOG, MRCGP
Primary Care Medical Director
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