On 8/5/2024, Sidra was wrongly prescribed sodium acid phosphate rather than sodium chloride. This was prescribed at approximately 5 times the recommended dose for a neonate of her size. This mis-prescription and overdose directly led to and caused hypocalcaemia and bradycardia, exacerbated by long QT syndrome, now apparent on ECG. The phosphate was lowered rather than stopped at around 1500, just after a 4th dose had been administered, following contact from the pharmacy. The drug error was not communicated to the consultant at the material time. The hypocalcaemia was apparent on blood gas analysis from approximately 0200 on 9/5/2024, but not recognised by clinicians until approximately 18:20, and corrective treatment started at approximately 19:30. Expert opinion was sought and all treatment given. Despite this, Sidra continued to deteriorate to her death at 00:12 10/5/2024. 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. Conclusion of the coroner as to the death: Accident contributed to by neglect. Evidence Relevant to the Matters of Concern: Extensive evidence was taken during the inquest, from the pharmacist, nurses and doctors and the pathologist. though Sidra's mother had received care
Desperately sad case. We need multidisciplinary teams that use EHRs in NICU/PICU settings to step through their processes & come up with short, medium and long term risk reduction strategies/system-based interventions to prevent future cases #MedSafety #NICUMeds www.judiciary.uk/prevention-o...