Recipient

Great Ormond Street Hospital

First report 14 Mar 2018•Latest report 21 Jan 2026

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Great Ormond Street Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

21 Jan2026
Inner West London
Concerns raised4
1. Drug-selection errors associated with drop-down menu prescribing for similarly named drugs
2. Failure to establish early-pregnancy diagnostic planning systems for at-risk newborns with long QT
3. Failure of on-call paediatric cardiology communication between team members and hospital teams seeking advice
1. Failure of neonatal doctors to obtain primary advice from the in-house visiting paediatric cardiology team
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

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.

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 Great Ormond Street 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 Great Ormond Street 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 Great Ormond Street 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 Great Ormond Street 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
14 Mar2018
Inner North London
Concerns raised2
1. Failure to communicate genetic test results accurately
2. Failure of genetic testing to detect a pathogenic gene mutation
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

Freddie Oliver DOBINSON-EVANS · 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

Freddie Dobinson-Evans had undiagnosed Dravet syndrome and died from causes recorded as post-cardiac arrest syndrome and Dravet syndrome. A genetic test report was communicated to his father as “absolutely normal”, although Freddie had a pathogenic SCN1A gene mutation; the report identified the potential for significant consequences for another child.

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 Great Ormond Street Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate genetic test results accurately
Wider context from the report
“Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. ████████ spoke to Freddie’s father the following day and told him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. ”
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 Great Ormond Street Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of genetic testing to detect a pathogenic gene mutation
Wider context from the report
“Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. ████████ spoke to Freddie’s father the following day and told him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Drug-selection errors associated with drop-down menu prescribing for similarly named drugs

Failure to establish early-pregnancy diagnostic planning systems for at-risk newborns with long QT

Failure of on-call paediatric cardiology communication between team members and hospital teams seeking advice

Failure of neonatal doctors to obtain primary advice from the in-house visiting paediatric cardiology team

Concerns raised2

Failure to communicate genetic test results accurately

Failure of genetic testing to detect a pathogenic gene mutation