Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0031, written 21 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2026 |
|---|---|
| Reference | 2026-0031 |
| Deceased | Sidra Aliabase |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Chelsea and Westminster Hospital, 369, Fulham Road, London. SW10 9NH c/o legal Chief Executive, Great Ormond Street Hospital, Great ormond Street, London. WC1N 3JH c/o legal 1 CORONER I am Professor Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London 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 13th and 14th January 2026 evidence was heard touching the death of Ms Sidra Aliabase. She had died at Chelsea and Westminster Hospital on 10th May 2026, aged 3 weeks. Medical Cause of Death Ia Iatrogenic hypocalcaemia and long QT Syndrome II Complications of prematurity, pulmonary artery stenosis with right ventricular hypertrophy and intrauterine growth restriction How, when and where the deceased came by her death. Sidra was born on 19/4/2024 at Chelsea and Westminster Hospital by emergency caesarean section at 27 weeks and 1 day gestation. She was very small and needed help with breathing and nutrition and was admitted to neonatal intensive care (NICU). She suffered an episode of sepsis in her second week of life. Sidra had a 50% chance of suffering with long QT syndrome. This risk had been recognised prenatally but no plan put in place to expedite diagnosis at birth. Expert opinion in relation to long QT was sought from Great Ormond Street Hospital but not adequately communicated back to the team at Chelsea and Westminster Hospital. Sidra was diagnosed with patent ductus arteriosus by the visiting paediatric cardiologist from the Royal Brompton Hospital who also requested an ECG on 30/4/2024. On 8/5/2024, Sidra was wrongly prescribed sodium acid phosphate rather than sodium chloride. This was prescribed at approximately 5 times the recommended dose for a neonate of her size. This mis-prescription and overdose directly led to and caused hypocalcaemia and bradycardia, exacerbated by long QT syndrome, now apparent on ECG. The phosphate was lowered rather than stopped at around 1500, just after a 4th dose had been administered, following contact from the pharmacy. The drug error was not communicated to the consultant at the material time. The hypocalcaemia was apparent on blood gas analysis from approximately 0200 on 9/5/2024, but not recognised by clinicians until approximately 18:20, and corrective treatment started at approximately 19:30. Expert opinion was sought and all treatment given. Despite this, Sidra continued to deteriorate to her death at 00:12 10/5/2024. The failure to prescribe the medication correctly was a failure in basic care and this was compounded by the failure to recognise the hypocalcaemia and the mis-prescribing across multiple shifts and clinical disciplines. Conclusion of the coroner as to the death: Accident contributed to by neglect. 4 Evidence Relevant to the Matters of Concern: Extensive evidence was taken during the inquest, from the pharmacist, nurses and doctors and the pathologist. Although Sidra’s mother had received care from the Royal Brompton Hospital (RBH) and the expert cardiology obstetric team at Chelsea and Westminster(C&W), as she suffered with autosomal dominant long QT, and had 2 elder sisters with the same condition, no plan had been put in place to expedite diagnosis at birth. The team should also have been on notice for the possibility of a premature delivery since both her sisters had been born prematurely. RBH provides an outreach paediatric cardiology service to C&W, with a visiting paediatric cardiologist, but instead of making use of this service, the neonatal team at C&W contacted GOSH for advice as Sidra’s sisters were under GOSH, even though GOSH would not likely play an active role until discharge and Sidra was unlikely to be discharged for some time. The GSOH on call paediatric registrar was contacted and gave phone advice including avoiding meds that could predispose to arrhythmia and ensuring electrolyte levels were within the normal range, and to undertake a 12 lead ECG to assist with diagnosis, but did not seek advice re genetic testing nor alert the consultant caring for Sidra’s sisters, leaving the onus on C&W to call back. The team at C&W recalled GOSH then emailed the paediatric cardiology consultant directly, who made a suggested management plan, but this was not transmitted to C&W. This led to potential delays in diagnosis and the prescribing of prophylactic treatment for the risk of tachyarrhythmias (beta blockers) and genetic testing, which were unfortunate, but did not contribute to the death. The court accepted evidence that treatment with beta blockers would not have protected against the subsequent hypocalcaemic induced bradycardia that led to Sidra’s death. A finding was made by the court that it would have been more sensible for C&W to seek advice from the in house RBH team when genetic testing would likely have happened promptly and diagnosis been made earlier, and later transfer to GOSH on discharge if Sidra would have been better cared for at the same hospital as her sisters. As above, this did not contribute to the death but would have reduced the risk of tachyarrhythmias developing in an already very premature and unwell baby. Overnight 8th to 9th May 2024, Sidra developed progressive hypocalcaemia and bradycardia. The bradycardia was wrongly thought to be due to a change in route of opiate administration by the night team who missed hypocalcaemia and wrong prescribing. By the morning of 9th May 2024 her bradycardia was worsening, and long QT was grossly apparent on her heart trace monitor. IV lines and electrolyte blood testing were requested, as electrolyte disturbance can cause or exacerbate arrhythmias and expert advice sought from the RBH. However once more, hypocalcaemia and the prescribing error was missed. Sidra went on to deteriorate and died as a direct result of the error in prescribing both the incorrect medication and in overdose. ( Excess phosphate binds calcium reducing blood levels of calcium and predisposing to bradycardia.) This was exacerbated by the failures to check blood results and prescribing at ward rounds and on administration of the phosphate by nursing staff on the 8th and 9th May 2024, and the failure to escalate hypocalcaemia on blood gas results by the nursing team, such that it was not noticed until 18:20. The error in prescribing was noted by the pharmacist around 11:30. Attempts were made by the pharmacist to contact the prescribing doctor, and finally communicated to the prescribing doctor at around 14:30. The court accepted the evidence of the pharmacist that they had checked Sidra’s records and noted hyponatraemia and suggested to the doctor that sodium chloride should have been prescribed rather than sodium acid phosphate, as well as advising that phosphate had been prescribed in overdose. The prescribing doctor simply reduced the phosphate dose at around 1500 and stated that they chased electrolyte blood test results, which should have been taken on the 8th May and already taken earlier on the 9th May but had not been. The doctor did not look at blood gas results where they could have seen calcium levels, if not phosphate, and did not inform the consultant attempting to manage the bradycardia, nor complete datix. This led to even more delay in treating the hypocalcaemia and recognising the cause of the bradycardia. The court found that the effect of phosphate overdose on calcium is something that the prescribing doctor should have been aware of and communicated to the consultant. The fact that the prescribing doctor went on to chase Sidra’s electrolyte levels, and retake them their self, after being made aware of their prescribing errors supported this finding. It was not until the morning after Sidra’s death that the prescribing doctor informed the consultant of their errors, by which time the consultant was already aware. There were thus multiple missed opportunities to recognise the prescribing error and overdose and its effects in a timely fashion that may have improved the outcome for Sidra and prevented her death at the material time. The prescribing doctor described to the court that they had chosen the wrong drug from the drop-down menu. Since this death there has been training of staff around phosphate prescribing and the importance of hypocalcaemia and reporting of prescribing errors which is also now undertaken by the pharmacist if capable of causing moderate harm to the patient. The ward round proforma also now includes a review of medication prescribing and blood test results. Such changes have addressed many of the court’s concerns. However, there are still a number of outstanding concerns as listed below. 5 Matters of Concern 1. That communications by the on call paediatric cardiology team at GOSH are not as they should be when they communicate between themselves and hospital teams that contact them for advice. 2. That systems for making plans for diagnosing long QT in newborns at risk need to be put in place early in pregnancy in case of premature delivery. 3. That Chelsea and Westminster neonatal doctors should take advice primarily from its in house visiting paediatric cardiology team for babies likely to be in hospital for some time, even if care is later transferred to another hospital service for long term follow up. 4. That drop-down menu prescribing is more likely to lead to errors in drug selection for drugs of similar names. 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. It is for each addressee to respond to matters relevant to them. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: c/o legal team I am also under a duty to send the Chief Coroner a copy of your response. 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 release or the publication of your response by the Chief Coroner. 9 21st January 2026 Professor Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner’s Court 65, Horseferry Road London SW1P 2ED Inner West London Coroner’s Court, 33, Tachbrook Street, London. SW1V 2JR Telephone:0207 641 8789.
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.
Medical Director’s Office Great Ormond Street Hospital for Children NHS Foundation Trust Great Ormond Street London WC1N 3JH Wednesday 18 March 2026 Professor Fiona J Wilcox HM Senior Coroner Inner West London Dear Madam, Following receipt of your regulation 28 Prevention of Future Deaths Report, Great Ormond Street Hospital NHS Foundation Trust (“the Trust”) has reviewed its current on-call paediatric cardiology service to identify and implement the necessary actions to ensure that patients like Sidra are cared for in the safest way possible in future. Whilst the Trust is encouraged to note that, in Sidra’s case, concerns relating to communication did not contribute to her death, it is entirely recognised that better communication results in more efficient coordination and the Trust acknowledges the important points raised in your Prevention of Future Deaths Report. When referrals are made into the Trust’s on-call cardiology service, the responsibility is on the referring trust to understand and apply the advice given in relation to their patient, but it is recognised that this relies on accurate documentation and understanding by the referring trust. For this reason, the Trust had already been exploring improvements to this service, some of which are already in place and some are well in progress and are directly relevant to this report. The actions of the Trust are primarily focussed on ways to improve the service moving forward but it should be noted that, as explained in further detail below, the current service is already improved insofar as the number of resident doctors on-call has doubled. This increase in available clinicians has already reduced the burden on the on-call service, as one clinician is designated to take incoming calls from external hospitals, whilst the other resident can focus on internal communication and communicating advice to, and following up with, external hospitals after referral into the service. The Trust hopes that these actions will give Sidra’s family some comfort and reassurance that the Trust has learnt from Sidra’s case to ensure that all patients at the Trust receive the highest standard of care. The actions which the Trust has taken, and those actions which are currently in progress, have been summarised below in response to the specific concern which has been raised. The Trust has recognised that improvements should be made to both the workforce and the systems within the on- call paediatric cardiology service and has devised solutions seeking to address both of those issues. Concern identified: Communications by the on-call paediatric cardiology team at GOSH are “not as they should be” when they communicate between themselves and hospital teams that contact them for advice (1) “Refer a Patient” online platform The Trust is currently working to implement a new patient referral system via an online platform, “Refer a Patient”. This system will allow other Trusts to refer patients into the Trust’s cardiology service without the need to use the on-call telephone service via an intuitive interactive online platform which will manage these referrals. A flow chart from the website, www.referapatient.org summarising how the system works is attached to this letter. The business case for adopting “Refer a Patient” within the Trust’s wider cardiology service is directly linked to the concerns identified by the Learned Coroner in Sidra’s case. Currently, referral processes rely heavily on phone calls and ad-hoc communication, which can be inefficient as the internal (GOSH) documentation in the Trust’s electronic patient records (EPIC) is not visible to external referrers. The responsibility sits with the referring team to document the advice given in their own notes and take the necessary actions. This fragmentation does not provide a transparent audit trail of decision-making. The goal is to ensure that any child in need of referral into the Trust’s cardiology service will be promptly triaged based on clear criteria, and that all referral information and decisions are centrally recorded. The “Refer a Patient” enables the documentation to be seen by both the external Trust and GOSH. It is anticipated that this identified action will improve the on-call paediatric cardiology team’s communication both internally and externally. In particular, it is anticipated that the introduction of this system will: (a) significantly reduce the pressure on the on-call telephone service; (b) appropriately triage referrals at the point of referral, whilst ensuring that the on-call telephone service is preserved for urgent clinical advice; and (c) keep a clear written history of any referral into the Trust’s cardiology team, which will in turn assist with internal management of referrals. Any advice given will be recorded and accessible by both the external trust and GOSH. As a result, it is expected that the streamlined referral process will significantly improve cardiology referrals into the service and improve communication both internally and externally in respect of any clinical advice which may be required. Most importantly, the systems allows a clear record of the discussion and advice given, that is accessible to the clinicians looking after a child at the referring hospital. An online referral triggers instant notifications and a rapid response, with prompts to referrers and the Trust’s clinical team, and provides the ability to communicate updates about a patient’s status. The digital platform will accelerate referral processing and decision-making. The system has been shown to significantly cut down the time from referral to treatment in other specialties (over a 60% reduction in time for national ECMO (extracorporeal membrane oxygenation) referral/response times)). Moreover, the platform enforces accountability for timely responses – every referral’s status is tracked until a decision is reached. The platform will be available 24/7. As above, the platform allows referrals to be appropriately triaged at the point of referral. The triage service will allow the Trust’s on-call function to serve urgent enquiries and longer- term requests and referrals, such as for genetic testing (which takes several weeks to process) with in-built mechanisms to monitor progress and ensure that requests are processed and followed up in a timely manner. The management team in the cardiology service at GOSH will maintain oversight of referrals into the cardiology service. All referral information, including patient data, referral reason, clinical notes, dialogue between referring and receiving clinicians and decisions will be logged on the ‘Refer a Patient’ system which can either be manually or automatically uploaded to the Trust’s electronic patient record (EPIC) creating a central documentation and audit trail accessible to both units. A secure, single data repository will eliminate the ‘rushed phone call’ scenario and ensure that critical information is accurately recorded and immediately available to the specialists who need it. As such, the audit trail of referral and advice (both that which is sought internally and provided externally) will assist in ensuring that requests into the cardiology service are actively pursued and a response provided in a timely manner, according to level of priority. Timescales In terms of timescales for implementation, there is a two-stage plan for implementing this system into the cardiology service. Firstly, the system will be implemented for heart transplant referrals and secondly, it will be extended to the wider cardiology service. The Trust has approved the business plan for implementing the heart transplant referral system within the 2026-27 financial year. In order to set up the heart transplant system, the vendor of the system provides a compliance compendium, then the Trust must undertake information governance and cyber security measures before the contract stage. The Trust must complete a Data Protection Impact Assessment (DPIA), a requirement under the General Data Protection Regulation, to identify and minimise data protection risks. The DPIA is a lengthy document and is near completion in relation to the heart transplant referral system. The Trust also needs to set up a risk register for data and complete an Information Governance Sharing Agreement prior to the contract completion stage. Once the contract has been signed, it is anticipated that it will take around three months for the heart transplant referral system to go live. After the contracts have been signed to implement the heart transplant referral system, the Trust will commence the same process for the wider cardiology referral system. It is anticipated that the preparation of the business plan, DPIA and associated documents will take around six months, and once the contracts are signed, a further three months for the cardiology referral system to go live. It is hoped that both the heart transplant referral platform and the wider cardiology service referral platform will be implemented in the 26/27 financial year. Wider communication strategy Prior to implementing the platform, the Trust will deploy its communication strategy, which includes informing all potential referrers that from the “go-live” date, referrals should be submitted via the platform. The Trust will also, as part of this strategy, contact usual referrers into the GOSH cardiology service to explain the process and to engage these Trusts with the new process. This strategy will be an ongoing piece of work with external Trusts to promote the creation of new referral habits. Referrers outside of the Trust’s network will be directed to the online platform when contact is made through other channels, for example a telephone call or email, as a prerequisite for the Trust accepting a referral. There will be a period of change supported by robust risk mitigation and ‘parallel working’, supporting the old ways of working for an agreed time whilst promoting the new ways of working. It is anticipated that there will be a short pilot period of a few months, prior to formally launching the system, whereby the platform is run in parallel to existing systems to ensure that all parties are comfortable in using the system, and to identify any potential issues are identified. The Refer a Patient platform has an Artificial Intelligence Doctors’ Assistant, AIDA, who guides referrers through the process by a series of questions. If a referrer is in doubt about the correct referral centre, an interactive map will be included. There will also be a link to the GOSH homepage with guidance on referrals, including information on the service and process. The on-call telephone service into the GOSH cardiology service will remain active, although as above, there will be an expectation that as external Trusts become familiar with the “Refer a Patient” platform, the on- call service will be reserved for cases requiring urgent, acute clinical advice. The online platform will not replace the availability of urgent telephone advice either at resident level or from the on-call consultant cardiologist. Clinician to clinician communication is still always encouraged by the platform. Helpfully, many external trusts will already be familiar with its use, as the platform is already used in over 80 hospitals nationally across different specialities. The platform was successfully implemented by the Royal Brompton and Harefield hospitals (Guys & St Thomas’ NHSFT) for ECMO referrals during the COVID-19 pandemic. The Trust is confident that the introduction of the “Refer a Patient” platform will significantly improve referrals into the Trust’s cardiology service and avoid some of the issues which became apparent as part of Sidra’s referral into the service. (2) Resident doctor availability At the time of Sidra’s tragic death, there was only one cardiology resident doctor covering the large influx of external calls during the day. The number of resident doctors covering external calls in cardiology has doubled since around July 2025; two resident doctors now manage the cardiology calls between 8.30am and 5.30pm when staffing allows. As with any NHS trust, staffing at GOSH is subject to resource availability. The increase in availability of on-call residents has improved the service as one resident doctor is able to handle new incoming calls from external trusts while the other resident can actively make calls to local hospitals to follow up on requests for advice. This improves the communication of the on-call service externally. Follow-up calls incorporate advice for patients currently under the care of other trusts, where the patient has been referred by that trust to the cardiology service at GOSH for advice but does not meet the criteria for transfer. It also incorporates patients who are awaiting transfer to GOSH. This means that hospitals, where patients who have been discussed with GOSH already, often receive a follow-up call. It also allows the other resident doctor more time and capacity to deal with incoming new referrals. There is no audit data available but we are confident that the doubling of residents within the daytime external service has improved the service. (3) Creation of guidelines including ECG proforma for referral network As part of the ongoing improvement work within the One Heart Network (which is the GOSH /Barts Operational Delivery Network for cardiology patients), the cardiology team is actively working to create guidelines which will be available to hospitals in the referral network, and on request to any hospitals outside the referral network. One such guideline is anticipated to be a proforma on interpreting ECGs. These guidelines will help clinicians external to the Trust identify cardiology problems and know when they should be making a referral to GOSH. Further to the “Refer a Patient” platform, it is anticipated that these guidelines will also assist with reducing the number of calls received into the on-call service, as external hospitals will be able to use the proforma to interpret an ECG and make an informed decision on whether the patient needs to be referred to the specialist service at GOSH. In order to extend the benefit of these guidelines, the cardiology team is considering uploading these guidelines onto the GOSH website. It is anticipated that a meeting will be scheduled to agree the next steps, likely by the end of 2026. (4) Cardiology teaching to referral network Whilst the cardiology team is currently focussing on producing the guidelines described above, there are also ongoing parallel discussions about potentially providing cardiology teaching to the wider referral network. This project is at an early stage with no planned implementation date as yet, but teaching topics would include guidance on how to deal with common referral calls, how to review ECGs and how to review QT intervals. If well received, such training could potentially also be rolled out beyond the referral network on request. The potential plans for training, in addition to the production of the guidelines, will be kept under review. The Trust is willing to provide Sidra’s family with regular updates on the progress that has been made, if they would find that beneficial. Yours Sincerely Acting Medical Director and Consultant Paediatric Neurologist Co-Medical Director North Thames Genomic Medicine Service Honorary Associate Professor, UCL Great Ormond Street Institute of Child Health
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