Tragic Baby Death Linked to Hospital Drop-Down Menu Prescribing Error
A three-week-old baby girl died after a doctor selected the wrong medication from a drop-down menu and prescribed it at five times the appropriate dose for her size, a coroner's inquest has heard. The heartbreaking case has exposed serious concerns about hospital communication systems and electronic prescribing risks.
Premature Birth and Genetic Heart Condition
Sidra Aliabase was born on April 19, 2024, by emergency caesarean section at just 27 weeks and one day of gestation. The extremely premature baby was very small and required assistance with both breathing and feeding, leading to her admission to neonatal intensive care.
Medical staff had identified that Sidra faced a 50 per cent chance of developing long QT syndrome, a genetic heart signaling disorder where the heart muscle takes too long to recharge between beats. Both of her older sisters had previously been diagnosed with the same condition.
Catalogue of Errors in Medication Administration
On May 8, 2024, a critical error occurred when a doctor prescribing medication for Sidra selected sodium acid phosphate instead of sodium chloride from a drop-down menu. The medication was not only the wrong drug but was prescribed at five times the recommended dosage for a baby of Sidra's size.
This prescribing mistake directly caused hypocalcaemia, a serious calcium deficiency, and bradycardia, a dangerous heart condition. Despite the fourth dose showing lowered phosphate levels, the error remained undetected and unreported to the consultant overseeing Sidra's care.
Multiple Failures in Basic Care
Coroner Fiona Wilcox, senior coroner for Inner West London, identified multiple systemic failures in her Prevention of Future Deaths report. The hypocalcaemia was apparent but went unrecognised by clinicians for more than 16 hours, during which time Sidra's condition continued to deteriorate.
The failure to prescribe the medication correctly was a failure in basic care, Ms Wilcox stated, and this was compounded by the failure to recognise the hypocalcaemia and the mis-prescribing across multiple shifts and clinical disciplines.
Communication Breakdown Between Hospitals
The inquest revealed concerning communication failures between Great Ormond Street Hospital, which had provided specialist advice, and Chelsea and Westminster Hospital, where Sidra was born and treated. Although the risk of long QT syndrome had been recognised prenatally, no formal management plan was established because experts at Great Ormond Street had not adequately communicated their findings back to the birth hospital.
Ms Wilcox noted particular concerns about how the on-call paediatric cardiology team at Great Ormond Street Hospital communicates with other hospital teams seeking their advice.
Electronic Prescribing Risks Highlighted
The coroner's report specifically highlighted the increased risk of error when using drop-down menus for drug selection, particularly for medications with similar names. The prescribing doctor admitted to the court that they had chosen the wrong drug from the electronic menu.
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 coroner concluded.
Inquest Conclusion and Ongoing Concerns
The inquest into Sidra's death, held in Inner West London, recorded a conclusion of accident contributed to by neglect. The official cause of death was confirmed as iatrogenic hypocalcaemia combined with long QT syndrome and complications of prematurity.
Sidra passed away at Chelsea and Westminster Hospital on May 10, 2024, after her condition deteriorated following the medication error. The coroner emphasised that the team should have been prepared for a premature delivery given both of Sidra's sisters had been born prematurely.
The court accepted evidence that standard treatment with beta blockers would not have protected against the hypocalcaemic-induced bradycardia that ultimately led to Sidra's death. By the morning of May 9, her bradycardia was worsening significantly, with long QT syndrome clearly apparent on her heart trace monitor.
Despite requests for IV lines and electrolyte blood testing, and despite seeking expert advice from Royal Brompton Hospital, the hypocalcaemia and prescribing error were missed yet again. The coroner noted that the effect of phosphate overdose on calcium levels was something the prescribing doctor should have recognised and communicated to the consultant.
The Daily Mail has contacted both Great Ormond Street Hospital and Chelsea and Westminster Hospital for comment regarding the tragic case and the coroner's findings.
