一家医院信托机构已对导致一名21个月大幼儿死亡的24项失误承担全部责任。
A hospital trust has taken full responsibility for 24 failures that led to the death of a 21-month-old.
埃莉诺·黑泽尔·阿尔德雷德-欧文（Eleanor Hazel Aldred-Owen）于2023年10月2日在利物浦的阿尔德海伊医院去世，一名验尸官得出结论称，她死于意外，疏忽是导致其死亡的原因之一。
Eleanor Hazel Aldred-Owen died at Liverpool's Alder Hey Hospital on 2 October 2023 - a coroner concluded she died as a result of misadventure, contributed to by neglect.
她因颅缝早闭（一种影响头骨的先天缺陷）接受了例行手术，但一份异常的胸部X光片未被标记。
She had routine surgery for craniosynostosis, a birth defect affecting the skull, but an abnormal chest X-ray was not flagged.
埃莉诺心脏骤停并遭受了无法生存的脑损伤，在父母的怀抱中离世。
Eleanor suffered a cardiac arrest and unsurvivable brain injury and died in her parents' arms.
她的家人来自弗林特郡莫尔德，他们表示，自那时起，他们一直生活在“无法承受”的内疚和创伤之中。
Her family, from Mold, Flintshire, said they have lived with "unbearable" guilt and trauma ever since.
阿尔德海伊儿童医院NHS基金会信托机构表示，她的“悲惨”死亡“本不该发生”。
Alder Hey Children's Hospital NHS Foundation Trust said her "tragic" death "should not have happened".
埃莉诺的父亲查兹（Chaz）表示：“不知道埃莉诺是如何以及为何死去的，这是关键因素，支撑我们坚持下去的是为她伸张正义。
Eleanor's dad Chaz said: "Not knowing how or why Eleanor died was the key factors and what kept us going was justice for her.
‘真正的胜利是确保埃莉诺身上发生的事情不会发生在其他人身上。没有其他家庭或儿童必须经历我们所经历的一切。’他补充说，他和妻子雷切尔（Rachel）‘相当确定这是疏忽’，但没有意识到严重程度，‘完全任由阿尔德海伊医院告诉我们情况’。
"The real victory is making sure what happened to Eleanor doesn't happen to anyone else. No other family or child will have to go through what we have." He added both he and his wife Rachel were "fairly certain it was neglectful" but did not realise the extent and were "at the mercy of what Alder Hey were telling us".
‘他们说是违反职责，而不是重大疏忽，信托机构花了很长时间才承认这一点。’他说，信托机构‘被迫承认重大疏忽’是最艰难的事情。
"They said it was breach of duty and not gross neglect and it took a long time for the trust to admit that." He said the trust "being compelled to admit gross neglect" was the hardest thing.
埃莉诺于2023年9月29日接受了针对颅缝早闭的例行手术，手术按计划进行，除了意外拔除了麻醉期间使用的呼吸管，该呼吸管随后由麻醉师重新置入，手术得以继续。
Eleanor had routine surgery for craniosynostosis on 29 September 2023 and it went as planned, apart from the accidental removal of the breathing tube used during anaesthetic, which was replaced by the anaesthetist and the procedure continued.
在恢复期间，埃莉诺心率加快并需要吸氧，院方决定启动AIRVO（一种高流量加温湿化吸氧设备），该设备未按信托机构的指南进行记录和处方。手术后，埃莉诺因手术导致肺塌陷。
During recovery, Eleanor had a raised heart rate and needed oxygen, and a decision was made to start AIRVO, a type of high-flow humidified oxygen, which was undocumented and not prescribed in accordance with trust's guidelines. After her operation, Eleanor developed a collapsed lung as a result of surgery.
一名放射技师未能向病房任何人标记她异常的胸部X光片，而医生没有立即对其进行复查，当时她正在急诊室复查另一名儿童。
A radiographer failed to flag her abnormal chest X-ray to anyone on the ward, and the doctor did not review it immediately because she was in A&E reviewing another child.
在肺塌陷被识别并治疗之前，埃莉诺发生了心脏骤停，导致了无法生存的脑损伤。一项调查发现，护理过程中存在24项失误，导致了她的死亡。
Eleanor had a cardiac arrest before the collapsed lung was identified and treated, causing an unsurvivable brain injury. An investigation found there were 24 failures in care that resulted in her death.
其中包括数次未能正确计算其儿科早期预警系统评分，这本应促成更早的医疗复查和胸部X光检查。
These included failure to correctly calculate her Paediatric Early Warning System score on several occasions, which would have led to a much earlier medical review and chest X-ray.
她的家人在一份声明中表示：‘埃莉诺的死是可以预防的，本不该发生。
In a statement, her family said: "Eleanor's death was preventable and should not have happened.
作为父母，这种内疚感是无法承受的，尽管我们知道是信托机构辜负了埃莉诺，而不是我们。我们的性格发生了不可逆转的改变。
"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.
我们不仅一直在为她悲伤，也在为女儿在这里时我们曾经的模样悲伤。’他们表示，他们认识到信托机构在埃莉诺死后实施的变革，但这些变革必须‘被妥善利用、接受持续审查，并为其他儿童的护理提供更多安全保障’。
"We don't just constantly grieve for her, we grieve for the people we used to be when our daughter was here." They said they recognised the changes the trust has implemented following Eleanor's death, but these had to be "used properly, kept under review and make care safer for other children".
查兹说，两项术后程序已被引入阿尔德海伊医院并以埃莉诺的名字命名，医院落实的改变是埃莉诺留下的遗产，也是他和妻子能够引以为傲的事情。
Chaz said two post-operative procedures had been brought in to Alder Hey and named after Eleanor and changes the hospital had put in place was Eleanor's legacy and something he and his wife could be proud of.
家人的律师、休·詹姆斯律师事务所合伙人琳达·雷诺兹（Lynda Reynolds）表示，这是“一个难以想象的悲惨案件”。
Lynda Reynolds, the family's solicitor and partner at Hugh James, said it was "an unimaginably tragic case".
“埃莉诺的父母信任阿尔德海伊儿童医院来照顾他们的女儿，却被辜负了。
"Eleanor's parents placed their trust in Alder Hey Children's Hospital to care for their daughter and were let down.
对于埃莉诺的家人来说，信托机构接受责任和公开道歉很重要，但这经历了一个漫长而痛苦的过程。
"For Eleanor's family, the trust's acceptance of responsibility and public apology are important, but this follows a long and painful process.
我们希望信托机构实施的变革能够继续为其他儿童的护理提供更多安全保障。”阿尔德海伊儿童医院NHS基金会信托机构表示，“失去埃莉诺的令人震惊的悲剧给我们所有人都留下了永恒的印记”。
"We hope that the changes the trust have implemented continue to make care safer for other children." Alder Hey Children's NHS Foundation Trust said "the shocking loss of Eleanor has left a permanent mark on us all".
“我们为辜负了埃莉诺和她的家人而心碎，我们希望确保这样的悲剧不再发生。”该机构补充说，错失的机会（包括未能上报严重异常的X光检查结果）促使其在放射科内部为严重异常和时间紧迫的检查结果引入了清晰的上报流程。
"We are heartbroken that we failed Eleanor and her family and we want to make sure that such a tragedy does not happen again." It added that the missed opportunities, including a failure to escalate grossly abnormal X-ray findings, led it to introduce a clear escalation process within the radiology department for grossly abnormal and time-critical findings.
信托机构对这些失误承担全部责任，并表示对这些失误导致埃莉诺死亡深表歉意。
The trust accepted full responsibility for these failures and said it was profoundly sorry they resulted in Eleanor's death.
查兹说，他不希望埃莉诺被遗忘，希望人们记住她本身的为人，而不是她是如何死去的。
Chaz said he does not want Eleanor to be forgotten and to be remembered for the person she was, not how she died.
“她快乐、坚强、有趣。她喜欢音乐和水。她爱我们，我们也爱她。”
"She was happy, strong and funny. She loved music and water. She loved us and we loved her."