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A coroner has raised concerns after a baby died as the result of a prescribing error in hospital, after being wrongly prescribed sodium acid phosphate instead of sodium chloride.
In a ‘Prevention of future deaths’ report (PFD), published on 21 January 2026, Fiona Wilcox, area coroner for Inner West London, said that three-week-old Sidra Aliabase was prescribed sodium acid phosphate “at approximately five 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 coroner said.
Aliabase was born premature at 27 weeks on 19 April 2024 and admitted to the neonatal intensive care unit (NICU), owing to needing help with her breathing and nutrition.
A risk of long QT syndrome had been noted prenatally but it was not identified that she had the condition at birth.
On 8 May 2024, Aliabase was wrongly prescribed sodium acid phosphate rather than sodium chloride. The error was noted by the pharmacist at 11:30 on the same day.
“Attempts were made by the pharmacist to contact the prescribing doctor, and finally communicated to the prescribing doctor at around 14:30,” the coroner wrote.
“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 coroner also noted that the prescribing doctor then “simply reduced” the phosphate dose at around 15:00 and stated that they had chased electrolyte blood results.
“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,” the coroner said.
The PFD added that this led to further delays in treating the hypocalcaemia and recognising the cause of bradycardia.
The prescribing doctor told the court that they had chosen the wrong drug from the drop-down menu.
Aliabase died at Chelsea and Westminster Hospital on 10 May 2024.
The coroner noted that since Aliabase’s death, there had been staff training on phosphate prescribing, the importance of hypocalcaemia and reporting 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,” she added.
However, the coroner said concerns still remain, such as that drop-down menu prescribing is more likely to lead to errors in drug selection for drugs with similar names.
The coroner issued the PFD to Chelsea and Westminster Hospital and Great Ormond Street Hospital, which have 56 days to respond with details of actions taken or proposed to be taken.
An investigation by The Pharmaceutical Journal into pharmacist staffing in neonatal and paediatric critical care, published in November 2025, found that just 13% of NHS hospital trusts met staffing standards for neonatal pharmacy.
Commenting on the case, Nigel Gooding, consultant pharmacist, neonates and paediatrics at Cambridge University Hospitals NHS Foundation Trust, said: “This unfortunate case demonstrates the need for improved availability of neonatal pharmacists on ward rounds to support medication review and prescribing.
“The recent Pharmaceutical Journal article on NICU pharmacist staffing shows that most centres are staffed at a level well below the Neonatal and Paediatric Pharmacy Group-recommended staffing levels and, in many cases, there is currently insufficient workforce to allow participation of pharmacists in ward rounds.
“The ‘Getting it right first time’ report on neonatology highlights that medication-related incidents are one of the top three reasons for incident reporting in a neonatal unit.
“The Royal College of Paediatrics and Child Health recently issued some best practice advice on medication reviews during paediatric ward rounds, which supports full review of medications each ward round. Although related to paediatrics, the principles of these medication reviews equally apply to neonatal ward rounds.”
He added: “There is also an opportunity for appropriate EMPA [electronic prescribing and medicines administration] systems to provide decision support for both prescribing and administration of medicines to try and prevent errors such as these occurring.
“However, although EPMA is being rolled out through many trusts, some of the systems do not allow appropriate prescribing for neonates and/or the decision support that is also required with an ability to highlight if a non-standard doses has been prescribed.”
Ashifa Trivedi, senior paediatrics pharmacist at Evelina London Children’s Hospital, said she was concerned not only about the initial prescribing error, but “what happens when that error is identified and cannot be immediately resolved?”.
“If a pharmacist recognises a high-risk prescribing error and is unable to contact the prescriber, there should be clear, time-critical escalation routes. Relying on repeated attempts to contact an individual doctor is not a safe system, particularly in neonatal care where deterioration can be rapid. The response should not depend on individual persistence.”
“Focusing training on phosphate alone also risks missing the wider issue. If systems are only strengthened around one medicine, the same sequence of events could easily recur with a different drug. Safety needs to be built around how errors are identified, escalated and acted upon,” she added.
“Blood results and medicines review should also be a routine, explicit part of every ward round. We have published a paper in Archives of Disease in Childhood, that showed that ward rounds are a key point where fragmented information comes together, and that structured medication review can reduce prescribing errors and offer an opportunity to identify warning signs.”
A spokesperson for Chelsea and Westminster Hospital NHS Foundation Trust commented: “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.”
