Tragic Death of Premature Baby Following Major Medication Error at London Hospital
A three-week-old premature baby has died at Chelsea and Westminster Hospital after a doctor administered a massive overdose of the incorrect medication. Sidra Aliabase, born at just 27 weeks and one day gestation, was given five times the recommended dose of a drug intended for treating high blood calcium, rather than the appropriate medication for her condition.
Systemic Failures and Missed Opportunities
Hospital staff failed to recognize their critical mistake for an alarming 16 hours, during which time Sidra's condition deteriorated irreversibly. The infant ultimately passed away in the early hours of May 10, 2024, at approximately 12:12 AM. HM Senior Coroner Professor Fiona J Wilcox has issued a formal warning to prevent similar tragedies, highlighting multiple systemic failures in basic care.
"The failure to prescribe the medication correctly was a failure in basic care," Professor Wilcox stated in her January 21 report. "This was compounded by the failure to recognize the hypocalcaemia and the mis-prescribing across multiple shifts and clinical disciplines. There were thus multiple missed opportunities to recognize the prescribing error and overdose and its effects in a timely fashion that may have improved the outcome for Sidra and prevented her death."
Chronology of Medical Errors
Sidra was born via emergency caesarean on April 19, 2024, and placed in neonatal intensive care due to her extreme prematurity. During her second week of life, she developed sepsis, further complicating her fragile health. On May 8, clinicians incorrectly prescribed sodium acid phosphate—a medication typically used to treat high blood calcium—instead of sodium chloride, which is standard treatment for low blood sodium.
The catastrophic error involved administering approximately five times the recommended dosage. This overdose caused Sidra's blood calcium levels and heart rate to plummet dangerously. Her condition was further aggravated by long QT syndrome, a genetic heart rhythm disorder that already affected her mother and two sisters, though no expedited diagnostic plan was implemented despite her 50% genetic risk.
Communication Breakdowns Between Hospitals
Critical information regarding Sidra's long QT syndrome was not adequately communicated between medical teams. While expert opinion was sought from Great Ormond Street Hospital, this vital consultation was not properly relayed back to clinicians at Chelsea and Westminster Hospital. Blood gas analysis from approximately 2:00 AM on May 9 clearly showed dangerously low calcium levels, yet this evidence went unnoticed by medical staff for over 16 hours.
The sodium phosphate medication was reduced—but not discontinued—after the hospital pharmacy intervened around 3:00 PM. Astonishingly, the prescribing error remained uncommunicated to the consultant until 6:20 PM, when clinicians finally recognized their mistake. Corrective treatment began approximately one hour later, but by then, Sidra's condition had deteriorated beyond recovery.
Complex Medical History and Official Cause of Death
Sidra's medical complications were extensive. In addition to her prematurity and long QT syndrome, she had been diagnosed with patent ductus arteriosus—a persistent opening between two major heart blood vessels—by a visiting pediatric cardiologist from Royal Brompton Hospital. An ECG had been requested on April 30 but did not prevent the subsequent medication error.
The official cause of death was determined to be iatrogenic hypocalcaemia (medically induced calcium deficiency), long QT syndrome, and complications of prematurity, including pulmonary artery stenosis with right ventricular hypertrophy and intrauterine growth restriction.
Hospital Responses and Ongoing Investigations
A spokesperson for Chelsea and Westminster Hospital NHS Foundation Trust expressed profound condolences: "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 to 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."
Great Ormond Street Hospital also responded: "We would like to offer our heartfelt condolences to Sidra's family. We recognize 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."
This tragic case highlights critical vulnerabilities in hospital medication protocols, inter-hospital communication systems, and monitoring procedures for vulnerable neonatal patients. The coroner's warning emphasizes the urgent need for systemic improvements to prevent similar preventable deaths in the future.
