3-week-old baby dies in UK after doctor chose wrong medication on drop-down menu

A three-week-old baby girl from the UK has died after a National Health Service (NHS) doctor selected the wrong drug from a drop-down menu, according to a report published by the UK's Court and Tribunals Judiciary.

The report detailed how Sidra Aliabase, who was born 13 weeks premature, was given the wrong medication that was prescribed at five times the recommended dosage.

Doctors and nurses did not notice the error, and the baby girl's health deteriorated over the next two days.

She died on May. 10, 2024.

After her death, the coroner, Fiona Wilcox, said that her death was an "accident contributed to by neglect".

"The failure to prescribe the medication correctly was a failure in basic care and this was compounded by the failure to recognise the hypocalcaemia and the mis-prescribing across multiple shifts and clinical disciplines."

Born 13 weeks premature with heart condition

Sidra was born on Apr. 19, 2024, at Chelsea and Westminster Hospital via emergency c-section at 27 weeks and one day of gestation.

"She was very small and needed help with breathing and nutrition and was admitted to neonatal intensive care (NICU)."

Court documents stated that Sidra had a 50 per cent chance of growing up with a heart disorder, called Long QT Syndrome (LQTS), and it had been recognised prenatally.

Long QT Syndrome (LQTS) is a genetic disorder in which the heart's electrical system takes too long to recharge between beats.

In her second week of life, the baby girl suffered an episode of sepsis.

On May 8, 2024, Sidra was wrongly prescribed sodium acid phosphate rather than sodium chloride, commonly known as table salt.

Sodium acid phosphate is typically used as a medication to treat low blood phosphate levels or manage high calcium levels.

The doctor also prescribed the wrong medication at approximately five times the recommended dose for a premature baby of Sidra's size.

This drastically lowered calcium levels in Sidra's blood, causing hypocalcaemia that resulted in a slowed heart rate.

But her hypocalcaemia went unnoticed by clinicians for over 16 hours.

Drug error communicated to staff too late

The phosphate was lowered, but not stopped, shortly after a fourth dose had been administered, following contact from the hospital's pharmacy on the same day.

But the drug error was still not communicated to the consultant.

Clinicians only noticed the error on May. 9, 2024, at 6:20pm. Corrective treatment began about an hour later.

Expert opinion was sought and treatment was given, but Sidra continued to deteriorate.

She died at May 10, 2024 at 12:12am local time. The cause of death was confirmed as iatrogenic hypocalcaemia (calcium deficiency) and long QT syndrome.

Missed opportunities

The report said that Sidra had died as a "direct result" of the error, and that there were "multiple missed opportunities" to recognise it.

The prescribing doctor only informed the consultant of their errors the morning after Sidra's death, by which time the consultant was already aware.

The report also acknowledged outstanding concerns, such as the drop-down menu leading to errors of drugs with similar names.

Spokespersons of both hospitals involved spoke to The Daily Mail expressing their deepest condolences.

Top photo from Canva