Sidra Aliabase

Dear Madam,

Following receipt of your regulation 28 Prevention of Future Deaths Report, Great Ormond Street Hospital NHS Foundation Trust (“the Trust”) has reviewed its current on-call paediatric cardiology service to identify and implement the necessary actions to ensure that patients like Sidra are cared for in the safest way possible in future.

Whilst the Trust is encouraged to note that, in Sidra’s case, concerns relating to communication did not contribute to her death, it is entirely recognised that better communication results in more efficient coordination and the Trust acknowledges the important points raised in your Prevention of Future Deaths Report.

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.

The actions of the Trust are primarily focussed on ways to improve the service moving forward but it should be noted that, as explained in further detail below, the current service is already improved insofar as the number of resident doctors on-call has doubled. This increase in available clinicians has already reduced the burden on the on-call service, as one clinician is designated to take incoming calls from external hospitals, whilst the other resident can focus on internal communication and communicating advice to, and following up with, external hospitals after referral into the service.

The Trust hopes that these actions will give Sidra’s family some comfort and reassurance that the Trust has learnt from Sidra’s case to ensure that all patients at the Trust receive the highest standard of care.

The actions which the Trust has taken, and those actions which are currently in progress, have been summarised below in response to the specific concern which has been raised. The Trust has recognised that improvements should be made to both the workforce and the systems within the on- call paediatric cardiology service and has devised solutions seeking to address both of those issues.

Concern identified: 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

(1) “Refer a Patient” online platform

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.

The business case for adopting “Refer a Patient” within the Trust’s wider cardiology service is directly linked to the concerns identified by the Learned Coroner in Sidra’s case. Currently, referral processes rely heavily on phone calls and ad-hoc communication, which can be inefficient as the internal (GOSH) documentation in the Trust’s electronic patient records (EPIC) is not visible to external referrers. The responsibility sits with the referring team to document the advice given in their own notes and take the necessary actions. This fragmentation does not provide a transparent audit trail of decision-making.

The goal is to ensure that any child in need of referral into the Trust’s cardiology service will be promptly triaged based on clear criteria, and that all referral information and decisions are centrally recorded. The “Refer a Patient” enables the documentation to be seen by both the external Trust and GOSH.

It is anticipated that this identified action will improve the on-call paediatric cardiology team’s communication both internally and externally. In particular, it is anticipated that the introduction of this system will:

(a) significantly reduce the pressure on the on-call telephone service; (b) appropriately triage referrals at the point of referral, whilst ensuring that the on-call telephone service is preserved for urgent clinical advice; and (c) keep a clear written history of any referral into the Trust’s cardiology team, which will in turn assist with internal management of referrals. Any advice given will be recorded and accessible by both the external trust and GOSH.

As a result, it is expected that the streamlined referral process will significantly improve cardiology referrals into the service and improve communication both internally and externally in respect of any clinical advice which may be required. Most importantly, the systems allows a clear record of the discussion and advice given, that is accessible to the clinicians looking after a child at the referring hospital.

An online referral triggers instant notifications and a rapid response, with prompts to referrers and the Trust’s clinical team, and provides the ability to communicate updates about a patient’s status. The digital platform will accelerate referral processing and decision-making. The system has been shown to significantly cut down the time from referral to treatment in other specialties (over a 60% reduction in time for national ECMO (extracorporeal membrane oxygenation) referral/response times)).

Moreover, the platform enforces accountability for timely responses – every referral’s status is tracked until a decision is reached.

The platform will be available 24/7. As above, the platform allows referrals to be appropriately triaged at the point of referral. The triage service will allow the Trust’s on-call function to serve urgent enquiries and longer- term requests and referrals, such as for genetic testing (which takes several weeks to process) with in-built mechanisms to monitor progress and ensure that requests are processed and followed up in a timely manner. The management team in the cardiology service at GOSH will maintain oversight of referrals into the cardiology service.

All referral information, including patient data, referral reason, clinical notes, dialogue between referring and receiving clinicians and decisions will be logged on the ‘Refer a Patient’ system which can either be manually or automatically uploaded to the Trust’s electronic patient record (EPIC) creating a central documentation and audit trail accessible to both units. A secure, single data repository will eliminate the ‘rushed phone call’ scenario and ensure that critical information is accurately recorded and immediately available to the specialists who need it.

As such, the audit trail of referral and advice (both that which is sought internally and provided externally) will assist in ensuring that requests into the cardiology service are actively pursued and a response provided in a timely manner, according to level of priority.

Timescales

In terms of timescales for implementation, there is a two-stage plan for implementing this system into the cardiology service. Firstly, the system will be implemented for heart transplant referrals and secondly, it will be extended to the wider cardiology service. The Trust has approved the business plan for implementing the heart transplant referral system within the 2026-27 financial year.

In order to set up the heart transplant system, the vendor of the system provides a compliance compendium, then the Trust must undertake information governance and cyber security measures before the contract stage. The Trust must complete a Data Protection Impact Assessment (DPIA), a requirement under the General Data Protection Regulation, to identify and minimise data protection risks. The DPIA is a lengthy document and is near completion in relation to the heart transplant referral system.

The Trust also needs to set up a risk register for data and complete an Information Governance Sharing Agreement prior to the contract completion stage. Once the contract has been signed, it is anticipated that it will take around three months for the heart transplant referral system to go live.

After the contracts have been signed to implement the heart transplant referral system, the Trust will commence the same process for the wider cardiology referral system.

It is anticipated that the preparation of the business plan, DPIA and associated documents will take around six months, and once the contracts are signed, a further three months for the cardiology referral system to go live.

It is hoped that both the heart transplant referral platform and the wider cardiology service referral platform will be implemented in the 26/27 financial year.

Wider communication strategy

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. There will be a period of change supported by robust risk mitigation and ‘parallel working’, supporting the old ways of working for an agreed time whilst promoting the new ways of working.

It is anticipated that there will be a short pilot period of a few months, prior to formally launching the system, whereby the platform is run in parallel to existing systems to ensure that all parties are comfortable in using the system, and to identify any potential issues are identified.

The Refer a Patient platform has an Artificial Intelligence Doctors’ Assistant, AIDA, who guides referrers through the process by a series of questions. If a referrer is in doubt about the correct referral centre, an interactive map will be included. There will also be a link to the GOSH homepage with guidance on referrals, including information on the service and process.

The on-call telephone service into the GOSH cardiology service will remain active, although as above, there will be an expectation that as external Trusts become familiar with the “Refer a Patient” platform, the on- call service will be reserved for cases requiring urgent, acute clinical advice. The online platform will not replace the availability of urgent telephone advice either at resident level or from the on-call consultant cardiologist. Clinician to clinician communication is still always encouraged by the platform.

Helpfully, many external trusts will already be familiar with its use, as the platform is already used in over 80 hospitals nationally across different specialities. The platform was successfully implemented by the Royal Brompton and Harefield hospitals (Guys & St Thomas’ NHSFT) for ECMO referrals during the COVID-19 pandemic.

The Trust is confident that the introduction of the “Refer a Patient” platform will significantly improve referrals into the Trust’s cardiology service and avoid some of the issues which became apparent as part of Sidra’s referral into the service.

(2) Resident doctor availability

At the time of Sidra’s tragic death, there was only one cardiology resident doctor covering the large influx of external calls during the day.

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.

The increase in availability of on-call residents has improved the service as one resident doctor is able to handle new incoming calls from external trusts while the other resident can actively make calls to local hospitals to follow up on requests for advice. This improves the communication of the on-call service externally.

Follow-up calls incorporate advice for patients currently under the care of other trusts, where the patient has been referred by that trust to the cardiology service at GOSH for advice but does not meet the criteria for transfer. It also incorporates patients who are awaiting transfer to GOSH. This means that hospitals, where patients who have been discussed with GOSH already, often receive a follow-up call. It also allows the other resident doctor more time and capacity to deal with incoming new referrals.

There is no audit data available but we are confident that the doubling of residents within the daytime external service has improved the service.

(3) Creation of guidelines including ECG proforma for referral network

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.

These guidelines will help clinicians external to the Trust identify cardiology problems and know when they should be making a referral to GOSH. Further to the “Refer a Patient” platform, it is anticipated that these guidelines will also assist with reducing the number of calls received into the on-call service, as external

hospitals will be able to use the proforma to interpret an ECG and make an informed decision on whether the patient needs to be referred to the specialist service at GOSH.

In order to extend the benefit of these guidelines, the cardiology team is considering uploading these guidelines onto the GOSH website. It is anticipated that a meeting will be scheduled to agree the next steps, likely by the end of 2026.

(4) Cardiology teaching to referral network

Whilst the cardiology team is currently focussing on producing the guidelines described above, there are also ongoing parallel discussions about potentially providing cardiology teaching to the wider referral network. This project is at an early stage with no planned implementation date as yet, but teaching topics would include guidance on how to deal with common referral calls, how to review ECGs and how to review QT intervals.

If well received, such training could potentially also be rolled out beyond the referral network on request.

The potential plans for training, in addition to the production of the guidelines, will be kept under review.

The Trust is willing to provide Sidra’s family with regular updates on the progress that has been made, if they would find that beneficial.

Dear Senior Coroner, Professor Wilcox, Inquest touching the death of Sidra Ibrahim (Sidra Aliabase) - Response to Prevention of Future Deaths Report issued 21 January 2026. I am the Chief Executive Officer writing on behalf of the Chelsea and Westminster Hospital NHS Foundation Trust, in response to the Regulation 28 report issued by the court on 21 January 2026, in relation to the death of Sidra Aliabase on 10 May 2024. We thank the Senior Coroner for bringing the concerns to the Trust's attention and aim to address them in this response. Firstly, on behalf of the Trust, I offer my sincere condolences to Sidra's parents and family. We wish to reassure them that the care and service delivery concerns identified during the inquest process have been reflected upon and learned from. Matter of Concern
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. The Trust has been in contact with and confirmed that Great Ormond Street Hospital ("GOSH") are intending to address this concern. The Trust therefore defers to GOSH in respect of this point.
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 ofpremature delivery. 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. In cases where women continue a pregnancy with a baby that requires multidisciplinary input, a weekly PIMS (Perinatal integrated Multidisciplinary Service) meeting consisting of fetal medicine, neonatal, paediatric surgical, paediatric urology, genetic and fetal cardiology consultants, neonatal nurses and fetal medicine midwives will take place. The multidisciplinary team will review each patient on a case by case basis to consider whether they will benefit from further antenatal screening, appointments, scans and/or monitoring. In line with routine national schedule of Antenatal care and national screening guidance, the Trust may offer an appointment at 28-30 weeks to discuss implications of antenatal findings and further management, including care planning for delivery and post-natal care. Where appropriate, birth and care plans will be developed and discussed with the patient and a Consultant Neonatologist. Following receipt of the Regulation 28 report, the Trust has identified that there was a gap in the guidelines for mothers at risk of pre-term labour. Whilst long QT syndrome in a baby is not a precursor to premature delivery, it is recognised that in this case, Sidra's mother had risk factors that ought to have led to earlier care planning for Sidra when she was delivered. Whilst there was a clear care and management plan in place for Sidra's mother, the presence of maternal risk factors highlights the importance of earlier neonatal care planning in similar cases.

[Page 2] NHS Chelsea and Westminster Hospital NHS Foundation Trust 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. The Trust has a clear process in place, and babies with a strong family history of inherited arrhythmia syndromes, fetal anomalies, or suspected genetic syndromes should be referred promptly to the PIMS team, where cases are reviewed and a coordinated perinatal and neonatal management plan is agreed. Neonatal management plans are documented on the neonatal alert within the maternal electronic record and should be established as early as possible once viable gestation is reached, taking into account the risk of premature delivery. 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 Brampton Hospital (RBH) Arrhythmia Centre, where testing is undertaken. These measures will support earlier multidisciplinary planning and ensure that babies at risk of inherited cardiac conditions have a clearly documented neonatal management plan in place prior to delivery wherever possible. The Trust will ensure that the updated guideline is disseminated to relevant clinical teams and reinforced through neonatal induction and multidisciplinary practice.
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. As part of the Incident Review into Sidra's care, the Trust identified that whilst there was clear communication and care planning in respect of Sidra's mother with the in-house visiting cardiology team at Royal Brampton Hospital, more input should have been sought regarding Sidra's care planning. Babies with an abnormal cardiovascular examination or abnormal ECG (including superior QRS axis) should be discussed with the cardiology SpR at the Royal Brampton 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. 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.
4. That drop-down menu for prescribing is more likely to lead to errors in drug selection for drugs of similar names. 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. The medication prescribing tool is a contextual search within an overall order catalogue that automatically shows potential medication choices as a clinician continues to type in the search box, gradually decreasing as further text is provided.

[Page 3] NHS \/\/ Chelsea and Westminster Hospital NHS Foundation Trust Following receipt of the Regulation 28 Report, the Trust escalated this concern internally through the Electronic Patient Record Optimisation Group ("EPROG") and immediately reached out to Oracle who have recorded this on their incident reporting system. Oracle are due to respond to the Trust to confirm whether any system mitigations can be put in place to mitigate this risk in the future. The Trust has also reached out to other local Trusts who utilise Cerner to identify whether their processes are the same and identify further opportunities for adapting the system wherever possible to mitigate mis-selection. In the meantime, alongside the evidence of action taken during the inquest, the Trust has taken the following steps:
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.
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)
3. This case has been used as a pharmacy case study for NICU staff induction training in the week commencing 02 March 2026. 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 of 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. This case was also monitored through the Mortality Surveillance Group on 06 March 2026, to ensure learning from deaths is identified promptly and fed across the Organisation. The response to the Regulation 28 report was discussed in the Trust Quality Committee meeting on 02 March 2026. 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.