Hospital where baby died from contaminated food had ‘completely unsafe system’
An NHS hospital which fed four newborn babies contaminated food has admitted it had a “completely unsafe system” in place when the babies became infected.
The admission was made during evidence by a senior doctor at Guy’s and St Thomas’ Trust (GSTT), which led the investigation into the outbreak, at an inquest into the death of one of the premature babies.
Dr William Newsholme answered questions last week at the coroner’s inquest at Southwark in London into the death of Aviva Otte at St Thomas’ Hospital on January 2, 2014.
Newsholme was asked why the test results for the baby formula, which were carried out on 26 December 2013, were not received until 6 January, by which time the baby had already died and three others were ill.
He was asked whether he agreed that the long delay meant that “this is a completely unsafe system for preparing parenteral nutrition for the most vulnerable group of patients in your hospital”.
Newsholme, an infectious diseases consultant and the fund’s clinical lead for infection prevention and control, replied: “Yes, I would.”
The investigation focuses on the events surrounding the deaths of Aviva and two other babies, nine-day-old Yousef Al-Kharboush and one-month-old Oscar Barker, in an outbreak of Bacillus cereus five months later, also involving contaminated feed. Nineteen babies in nine hospitals were infected in that outbreak, three of whom died.
The inquiry also heard that Eileen Sills, the chief nurse at GSTT, raised concerns with colleagues at the time of the initial outbreak about a delay in alerting the infection control department and asked whether they should have acted more quickly. The recipients included Amanda Pritchard, who was GSTT’s chief operating officer at the time and has since become the chief executive of NHS England.
In her email of January 17, 2014, she asked them: “Can I ask you to look at the time when you first noticed the problem between the 24and Dec and 2nd January, should you have called in infection control to assess the risk before we had an outbreak in the NNU (neonatal unit)?”
Newsholme told the court that given the need for the foundation to be aware of the outbreak and take action to limit its impact, “this is a perfectly appropriate question for her (Sills) to ask”.
In 2022, The Guardian revealed that the first outbreak had occurred and that the GSTT had never publicly announced it, despite the fact that four highly vulnerable newborns had been infected.
Earlier this month, Dr Grenville Fox, another senior doctor at GSTT who had treated Aviva, told the inquest that she had indeed died as a direct result of the contaminated feed, contradicting the charity’s claim that her death was the result of “natural causes” for more than 10 years.
Asked in court last week why the “root cause analysis” report of his investigation into the first outbreak did not mention that one of the four infected babies had died, Newsholme said it was “an unfortunate omission” and did not explain. His report said only that four patients had become ill during the outbreak, of whom “three were considered to have moderate clinical deterioration”.
He was also asked why the GSTT had issued a “preliminary statement” to be given to any journalist who enquired about the initial outbreak, but had failed to warn the media that they were dealing with an outbreak of Bacillus cereusa potentially fatal infection.
In response, he told the court that “this is not any form of embezzlement or cover-up”.
Two weeks ago, another GSTT doctor, Anthony Kaiser, testified to coroner Dr. Julian Morris that the foundation’s handling of the outbreak, which was kept secret, was “not a cover-up.”
Aviva’s mother, Jedidajah, is a journalist for The Guardian. The investigation continues.