PFD report

Sidra Aliabase · Prevention of Future Deaths report

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Issued 21 Jan 2026•Inner West London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Drug-selection errors associated with drop-down menu prescribing for similarly named drugs
    Part of recurring concern: Unsafe medication prescribing
  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
    Part of recurring concern: Unreliable communication with cardiology teams about patient care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Maintain two daytime resident cardiology doctors to separate incoming external calls from follow-up communication and advice.

    Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  2. Action

    Reinforce cardiac referral pathways, cardiology advice processes and early care planning through neonatal induction for new and locum consultants.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  3. Action

    Update the fetal medicine guideline to prompt consideration of antenatal appointments before 28 weeks for appropriate high-risk cases.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Referring trusts are responsible for understanding and applying cardiology advice and documenting it in their own records.

    Stated by Great Ormond Street Hospital for Children NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable communication with cardiology teams about patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain two daytime resident cardiology doctors to separate incoming external calls from follow-up communication and advice.

Verbatim wording from the response

“The number of resident doctors covering external calls in cardiology has doubled since around July 2025; two resident doctors now manage the cardiology calls between 8.30am and 5.30pm when staffing allows. As with any NHS trust, staffing at GOSH is subject to resource availability.”

Source location

2026-0031 - Response from Great Ormond Street Hospital
Page 4 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reinforce cardiac referral pathways, cardiology advice processes and early care planning through neonatal induction for new and locum consultants.

Verbatim wording from the response

“This is being continually reinforced through the neonatal induction programme for new and locum consultants to ensure awareness of referral pathways, cardiology advice processes, and early multidisciplinary care planning for babies at increased cardiac risk.”

Source location

Response from Chelsea and Westminster Hospital
Page 2 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the fetal medicine guideline to prompt consideration of antenatal appointments before 28 weeks for appropriate high-risk cases.

Verbatim wording from the response

“The Trust is therefore updating the Guideline to ensure multidisciplinary teams consider cases where appointments prior to 28 weeks may be appropriate. It is considered that this should be on a case by case basis and clinical judgment as to when this appointment should take place will enable treating teams to recognised opportunities for earlier care planning particularly for babies with risk factors, including genetic conditions such as Long QT syndrome.”

Source location

Response from Chelsea and Westminster Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and implement a pregnancy and perinatal Long QT syndrome guideline covering neonatal assessment, monitoring, ECGs, genetic testing and sample referral.

Verbatim wording from the response

“The Trust is developing and implementing a guideline to be completed within the next 3 months, on the management of Long QT syndrome (LQTS) in pregnancy and the perinatal period, including clear recommendations for neonatal monitoring. The guideline will outline neonatal assessment including monitoring of heart rate and blood glucose at birth, a 12-lead ECG shortly after birth and again at approximately 3 weeks of age (or as advised by the cardiology team), and genetic testing where the familial pathogenic variant is known. It will also clarify the process for sending genetic samples to the Royal Brompton Hospital (RBH) Arrhythmia Centre, where testing is undertaken.”

Source location

Response from Chelsea and Westminster Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue and deliver updated guidance and training on safer Cerner drug-search practices to reduce medication-selection errors.

Verbatim wording from the response

“1. Issued further guidance to clinical teams on safer drug search practices in Cerner (e.g., entering more characters before selection) to mitigate mis-selection risk. This is already factored into training and has been updated to reflect the issues identified in Sidra's care. Training took place across the Acute Provider Collaborative (Imperial College Healthcare, Chelsea and Westminster Hospital NHS FT, The Hillingdon Hospitals and London North West University Healthcare) in the week of 02 March 2026, as well as in induction for new doctors.”

Source location

Response from Chelsea and Westminster Hospital
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide regular neonatal simulation training covering medication-selection error scenarios in in-situ and StiNE courses.

Verbatim wording from the response

“2. Simulation training is regularly given to the Neonatal team with this scenario for both in-situ and StiNE courses (simulation training in neonatal emergencies)”

Source location

Response from Chelsea and Westminster Hospital
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Referring trusts are responsible for understanding and applying cardiology advice and documenting it in their own records.

Verbatim wording from the response

“When referrals are made into the Trust’s on-call cardiology service, the responsibility is on the referring trust to understand and apply the advice given in relation to their patient, but it is recognised that this relies on accurate documentation and understanding by the referring trust. For this reason, the Trust had already been exploring improvements to this service, some of which are already in place and some are well in progress and are directly relevant to this report.”

Source location

2026-0031 - Response from Great Ormond Street Hospital
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing fetal medicine, multidisciplinary review and neonatal alert processes provide the established framework for antenatal and perinatal planning.

Verbatim wording from the response

“The Trust has an established Fetal Medicine Neonatal Pathway when risk factors for either the mother or their baby are identified antenatally, in line with the Trust's Fetal Anomaly Screening Programme Guidelines.”

Source location

Response from Chelsea and Westminster Hospital
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Oracle must determine whether mitigations can be implemented within the Cerner prescribing system to reduce drug-selection errors.

Verbatim wording from the response

“The Trust electronic patient system ("Cerner") is provided by Oracle. This is a nationally-distributed electronic system that supports NHS Trusts with appointments, admissions, theatre management, clinical note recording, observations and assessments, ordering procedures, discharging patients and medication administration.”

Source location

Response from Chelsea and Westminster Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

GOSH is responsible for addressing communication concerns within its paediatric cardiology team.

Verbatim wording from the response

“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.”

Source location

Response from Chelsea and Westminster Hospital
Page 1 · response
Published 26 January 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Create cardiology referral-network guidelines, including an ECG interpretation proforma, for use by external hospitals.

    Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  2. 2

    Implement the “Refer a Patient” online referral platform, initially for heart transplant referrals and then across the wider cardiology service.

    Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  3. 3

    Deploy and maintain a communication strategy to move external referrers onto the online referral platform and establish new referral practices.

    Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
  4. 4

    Disseminate the updated guideline to relevant clinical teams through neonatal induction and multidisciplinary practice.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
  5. 5

    Conduct ongoing monthly NICU prescription audits, provide targeted feedback and training when incomplete prescriptions are identified.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  6. 6

    Continue identifying and implementing organisation-wide measures to mitigate human error in medication prescribing, with internal monitoring and dissemination of learning.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  7. 7

    Use the case as a pharmacy case study in NICU staff induction training.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing hospital policy establishes the required cardiology referral and advice pathways for neonates with abnormal cardiovascular findings or ECGs.

    Stated by Chelsea and Westminster Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Create cardiology referral-network guidelines, including an ECG interpretation proforma, for use by external hospitals.

Verbatim wording from the response

“As part of the ongoing improvement work within the One Heart Network (which is the GOSH /Barts Operational Delivery Network for cardiology patients), the cardiology team is actively working to create guidelines which will be available to hospitals in the referral network, and on request to any hospitals outside the referral network. One such guideline is anticipated to be a proforma on interpreting ECGs.”

Source location

2026-0031 - Response from Great Ormond Street Hospital
Page 4 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the “Refer a Patient” online referral platform, initially for heart transplant referrals and then across the wider cardiology service.

Verbatim wording from the response

“The Trust is currently working to implement a new patient referral system via an online platform, “Refer a Patient”. This system will allow other Trusts to refer patients into the Trust’s cardiology service without the need to use the on-call telephone service via an intuitive interactive online platform which will manage these referrals. A flow chart from the website, www.referapatient.org summarising how the system works is attached to this letter.”

Source location

2026-0031 - Response from Great Ormond Street Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deploy and maintain a communication strategy to move external referrers onto the online referral platform and establish new referral practices.

Verbatim wording from the response

“Prior to implementing the platform, the Trust will deploy its communication strategy, which includes informing all potential referrers that from the “go-live” date, referrals should be submitted via the platform. The Trust will also, as part of this strategy, contact usual referrers into the GOSH cardiology service to explain the process and to engage these Trusts with the new process. This strategy will be an ongoing piece of work with external Trusts to promote the creation of new referral habits. Referrers outside of the Trust’s network will be directed to the online platform when contact is made through other channels, for example a telephone call or email, as a prerequisite for the Trust accepting a referral.”

Source location

2026-0031 - Response from Great Ormond Street Hospital
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate the updated guideline to relevant clinical teams through neonatal induction and multidisciplinary practice.

Verbatim wording from the response

“The Trust will ensure that the updated guideline is disseminated to relevant clinical teams and reinforced through neonatal induction and multidisciplinary practice.”

Source location

Response from Chelsea and Westminster Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct ongoing monthly NICU prescription audits, provide targeted feedback and training when incomplete prescriptions are identified.

Verbatim wording from the response

“The Trust undertakes an ongoing monthly detailed audit within the Neonatal Unit to identify any other prescribing errors. The prescription audit was initiated as an immediate action following Sidra's case, with the aim of monitoring prescription quality within the NICU. The audit's terms of reference currently involve reviewing all prescriptions for babies in the unit on the audit day. This process has facilitated spot checks and provided opportunities for direct learning. Whenever an incomplete prescription was identified—with a focus on omissions dose per kilogram—the staff involved were promptly notified, and the NICU education team offered targeted training support. This audit found no further medication errors resulting in harm.”

Source location

Response from Chelsea and Westminster Hospital
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue identifying and implementing organisation-wide measures to mitigate human error in medication prescribing, with internal monitoring and dissemination of learning.

Verbatim wording from the response

“The Trust is committed to continuing to identify and implement measures to mitigate the risk of human error in prescribing medication across the Organisation and this work is a direct result of the issues identified in Sidra's care, to prevent this happening in the future. This work will remain continuous to reflect changes in prescribing, systems process and/or national guidelines. Any developments are effectively monitored through various internal processes, including the Trust Quality Committee, to ensure learning is widely identified and disseminated across the Organisation.”

Source location

Response from Chelsea and Westminster Hospital
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use the case as a pharmacy case study in NICU staff induction training.

Verbatim wording from the response

“3. This case has been used as a pharmacy case study for NICU staff induction training in the week commencing 02 March 2026.”

Source location

Response from Chelsea and Westminster Hospital
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing hospital policy establishes the required cardiology referral and advice pathways for neonates with abnormal cardiovascular findings or ECGs.

Verbatim wording from the response

“Babies with an abnormal cardiovascular examination or abnormal ECG (including superior QRS axis) should be discussed with the cardiology SpR at the Royal Brompton Hospital (for Chelsea), which is the Trust's designated cardiac referral centre, or with the Paediatric Consultant and Service Director for Neonatology at West Middlesex Hospital, in line with already established Hospital policy.”

Source location

Response from Chelsea and Westminster Hospital
Page 2 · response
Published 26 January 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026