A prevention of future deaths report was published in January 2026, following the death of a premature infant at Chelsea & Westminster Hospital. A newborn patient was wrongly prescribed sodium acid phosphate instead of sodium chloride, leading to an overdose, a report from the coroner for Inner West London found. A Pharmaceutical Journal article on this incident can be viewed here: Prescribing error led to death of baby, says coroner – The Pharmaceutical Journal.

If you have use an electronic prescribing system at your organisation, please take a look and review how enteral phosphate preparations appear e.g. are they named sodium phosphate or sodium acid phosphate?  It is worth considering whether a similar prescribing error could happen on your neonatal unit and whether there are any steps you can take to mitigate this risk e.g. consider alternative ways of naming the products in your prescribing system or introduce indication-based prescribing e.g. for hyponatraemia,  sodium chloride would appear as the only prescribing option.