21 Jan 2026 Sidra Aliabase · Prevention of Future Deaths report Inner West London
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Concerns raised 4 Drug-selection errors associated with drop-down menu prescribing for similarly named drugs View source Failure to establish early-pregnancy diagnostic planning systems for at-risk newborns with long QT View source Failure of on-call paediatric cardiology communication between team members and hospital teams seeking advice View source Failure of neonatal doctors to obtain primary advice from the in-house visiting paediatric cardiology team View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sidra Aliabase · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sidra Aliabase was born prematurely at Chelsea and Westminster Hospital and later died there aged 3 weeks after being wrongly prescribed sodium acid phosphate instead of sodium chloride at approximately five times the recommended neonatal dose. The report describes concerns about communication between paediatric cardiology and hospital teams, delayed planning and diagnosis for long QT syndrome, reliance on appropriate cardiology advice, and prescribing systems that may contribute to errors involving similarly named drugs.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Drug-selection errors associated with drop-down menu prescribing for similarly named drugs
Wider context from the report “4. That drop-down menu prescribing is more likely to lead to errors in drug selection for drugs of similar names .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish early-pregnancy diagnostic planning systems for at-risk newborns with long QT
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of on-call paediatric cardiology communication between team members and hospital teams seeking advice
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatal doctors to obtain primary advice from the in-house visiting paediatric cardiology team
Wider context from the report “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.
” Open source report
2 Dec 2024 Elton Deutekom · Prevention of Future Deaths report Inner West London
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Concerns raised 10 Failure to disclose evidence relevant to deaths to the coroner under the duty of candor View source Insufficient supervision of newly qualified midwives managing women in labour View source Provision of assistance to write neonatal death records retrospectively View source Failure of neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations View source Lack of a regular CTG review system on the central CTG monitoring board View source Failure to appropriately refer neonatal deaths to the coroner View source Failure of neonatologists to appropriately report deaths to the coroner View source Lack of Medical Examiner access to obstetric records when reviewing deaths View source Understaffing of the labour ward View source Destruction of contemporaneous handwritten notes following neonatal deaths View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Elton Deutekom · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose evidence relevant to deaths to the coroner under the duty of candor
Wider context from the report “2. That Chelsea and Westminster hospital may not be complying with the duty of candor to disclose evidence relevant to a death to the coroner until forced to by court directions made in public , which thus raises the same concern as above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of newly qualified midwives managing women in labour
Wider context from the report “5. That newly qualified midwives should have more supervision whilst they are managing women in labour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Provision of assistance to write neonatal death records retrospectively
Wider context from the report “3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations
Wider context from the report “8. That the neonatologists at Chelsea and Westminster are not passing sufficient and appropriate information to the pathologists when consented post- mortem examinations occur such that the cause of death found by the pathologist may be inaccurate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a regular CTG review system on the central CTG monitoring board
Wider context from the report “6. That there is no regular review system for CTGs on the central CTG monitoring board .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately refer neonatal deaths to the coroner
Wider context from the report “1. That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all , and this raises the possibility that lessons may not be learned from the investigation of these deaths that may save the lives of others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatologists to appropriately report deaths to the coroner
Wider context from the report “9. That neonatologists in other hospitals may not be appropriately reporting deaths to the coroner .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of Medical Examiner access to obstetric records when reviewing deaths
Wider context from the report “7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Understaffing of the labour ward
Wider context from the report “4. That the labour ward is understaffed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Destruction of contemporaneous handwritten notes following neonatal deaths
Wider context from the report “3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
” Open source report
27 Oct 2023 Kai TAKAGI · Prevention of Future Deaths report Inner West London
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Concerns raised 4 Failure to track outstanding diagnostic results for patients leaving the Accident and Emergency Department View source Insufficient hospital capacity for callback of patients leaving the Accident and Emergency Department View source Failure to implement periodic clinician-led review of abnormal diagnostic results View source Lack of independently auditable callback handover View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Kai TAKAGI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kai Takagi attended Chelsea and Westminster Hospital on 11 June 2021 with severe stomach pain and left before an abnormal blood result, suggestive of acute pancreatitis, was received. The hospital planned to contact him but did not do so, and he was found dead at home on 14 June 2021; the stated medical cause of death was acute peritonitis from a perforated gastric ulcer. Concerns included inadequate tracking and follow-up of patients who leave with outstanding abnormal test results, reliance on oral handover, and incomplete implementation of a clinician-led review system.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to track outstanding diagnostic results for patients leaving the Accident and Emergency Department
Wider context from the report “(1) Patients that leave the hospital Accident and Emergency Department with outstanding blood results or other diagnostic tests are not followed up and “tracked” in the same way that in-patients are , thus giving rise to the risk that they are missed and urgent follow-up care is not actioned or offered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital capacity for callback of patients leaving the Accident and Emergency Department
Wider context from the report “(2) That as reliance on Accident and Emergency departments for routine out of hours health care increases, the burden of call back also increases for hospitals for patients who have left at a time when their departments are already over-stretched in dealing with admissions and those presenting to the department , thus increasing the risk that patients will not be called back for urgent follow-up assessment or treatment which may be life-saving.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to implement periodic clinician-led review of abnormal diagnostic results
Wider context from the report “(4) That a periodic clinician led review of all abnormal blood results (and other test results) , which the hospital has explored since I raised the matter in the hearing has not been fully implemented giving rise to the risk that patients who have left the hospital with potentially life-threatening conditions suggested by the tests may not be contacted urgently asking them to return thus increasing the risk of their untimely deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of independently auditable callback handover
Wider context from the report “(3) That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them. Short of an individual doctor being asked if the call back had been actioned, there is no way of checking that it has .
” Open source report
9 May 2018 Edward Joyce · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to provide advice to return to hospital after reported high temperature following a burn View source Failure to trigger urgent hospital referral for high temperature following a burn View source Failure to record reported high temperature in telephone notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Edward Joyce · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Joyce suffered an accidental scalding injury on 19 November 2017 and later developed septic shock from infected burns. He became severely unwell on 22 November and died despite attempts at resuscitation. Concerns included that a temperature of 38.9°C did not trigger an urgent hospital referral and was not recorded when his mother telephoned the hospital, and that parents were not advised to bring him back to hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice to return to hospital after reported high temperature following a burn
Wider context from the report “The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome.
(1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital.
(2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital .
(3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger urgent hospital referral for high temperature following a burn
Wider context from the report “The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome.
(1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital.
(2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital.
(3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chelsea and Westminster Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record reported high temperature in telephone notes
Wider context from the report “The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome.
(1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital.
(2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital.
(3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations