Coroner: Hospital's 'neglect' played role in 27-week preemie's 2024 death

A premature baby born in 2024 died after she was mistakenly administered five times the recommended dose of an incorrect medication — and a coroner has now determined that hospital "neglect" played a large role.

Key Takeaways:

• Sidra Aliabase was born at 27 weeks gestation in 2024 and was admitted to a London hospital.

• After being diagnosed with sepsis, doctors accidentally administered the baby a five-times higher dose of an incorrect medication. No one noticed the mistake for 16 hours, and she died.

• After examining the sequence of events, a coroner concluded this year that the baby girl's death was an “accident contributed to by neglect."

The Details:

On April 19, 2024, Sidra Aliabase was born at 27 weeks via emergency c-section at Chelsea and Westminster Hospital. During the second week of her life, while under the care of the neonatal staff, she fell ill with sepsis. In this case, the infant should have been prescribed sodium chloride, which is commonly used to treat low blood sodium; instead, she was wrongly administered sodium acid phosphate, a drug used to treat high blood calcium.

In addition to being given the wrong drug, Sidra was given five times the recommended dosage of that drug. 

A blood gas analysis showed that baby Sidra’s blood calcium levels were extremely low by 2:00 a.m. the morning after she received the first dose of the medication. However, this went unnoticed for over 16 hours.

Sidra was given the sodium acid phosphate three more times before the pharmacy noticed the error, with clinicians being made aware around 6:20pm.

Corrective measures were taken, yet sadly, Aliabase died on May 10, 2024, at 12:12 am.

According to the Standard, “Her cause of death was confirmed as iatrogenic hypocalcaemia, or calcium deficiency, and Long QT syndrome, along with complications of prematurity, pulmonary artery stenosis with right ventricular hypertrophy and intrauterine growth restriction.” 

Coroner's determination

This year, on January 13 and 14, Professor Fiona J Wilcox, HM Senior Coroner for the Coroner Area of Inner West London, brought Aliabase’s case before the Judiciary.

They initially looked at the original cause of death, but after examining the sequence of events, including...

1) the absence of a plan for hereditary long QT syndrome,

2) the mistaken order of the wrong medication (and lack of awareness compounded by the delayed order to stop the medication), and

3) the lack of attention to the deteriorating wellness of the infant by all staff involved, the coroner determined that the baby girl's death was an “accident contributed to by neglect."

Wilcox stated:

“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.

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.”

Zoom In:

Sidra Aliabase was born with Long QT Syndrome, a medical condition impacting the electrical system of the heart resulting in rapid heart rate and irregular rhythm. Her care team was aware there was a 50% chance she would be born with this abnormality, and sought expert opinion from Great Ormond Street Hospital. Yet somehow, there was a lack of proper communication to Chelsea and Westminster Hospital. 

A spokesperson for Chelsea and Westminster Hospital NHS Foundation Trust said:

We extend our deepest condolences to Sidra's family, and our thoughts remain with them at this difficult time. Our priority is always to provide the highest standard of care and we will be responding the coroner's report to confirm how the trust has taken steps to address the ongoing learning from these circumstances and to improve patient care.

A spokesperson for Great Ormond Street Hospital for Children (GOSH) added:

We would like to offer our heartfelt condolences to Sidra's family. We recognise that GOSH is often contacted for specialist advice and therefore it is important that our processes are clear and robust. We will look carefully at Sidra's care so we can understand what more we could have done and learn for the future.

The Bottom Line:

Afterward, the full report and conditions to be addressed were sent to the chief executives of both Chelsea and Westminster Hospital and Great Ormond Street Hospital.

They were given 56 days to respond with detailed explanations of the intended actions of prevention, or an explanation as to why that would not be done.