Great Ormond Street Hospital

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First report 14 Mar 2018•Latest report 21 Jan 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

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.

  1. Inner West London

    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

  2. Inner North London

    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
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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