Investigation launched in London into baby’s death due to contaminated IV food
A mother whose premature baby died in hospital after being fed contaminated intravenous food told her son during the child’s inquest it was “the worst experience a parent can go through.”
Yousef Al-Kharboush was nine days old when he died on June 1, 2014 at St. Thomas’ Hospital in London after developing sepsis from consuming liquid food infected with bacteria that Bacillus cereus.
He was one of 19 premature babies infected during a large outbreak in nine hospitals in 2014.
The inquest into Yousef’s death, as well as two other babies who died in separate outbreaks of contaminated food – one-month-old Oscar Barker, who also died in June 2014, and three-month-old Aviva Otte, who died in January 2014 – opened on Monday at Southwark coroner’s office.
The senior coroner, Dr Julian Morris, said his role was not to find blame but to identify the babies and how they died. The coroner revealed he was considering taking the unusual step of ordering a prevention of future deaths notice, a legal warning to one or more public or private bodies that they must take specific action to prevent further deaths in similar circumstances. Morris said: “The other duty I have to consider is whether I should produce a report on preventing future deaths – that is something I will consider as we hear the evidence in the coming weeks.”
Yousef and his twin brother were born at 32 weeks’ gestation via emergency caesarean section at St Thomas’ Hospital after their mother, Ghanda Al-Kharboush, was told one of the babies was not growing properly.
Although both twins were fed intravenously while in intensive care, only Yousef died.
Al-Kharboush said in a statement read to the court that she noticed Yousef was struggling when she went to express milk for him on May 30, 2014.
She spoke to a nurse about how “Yousef was not as vocal as usual” and his “breathing did not seem regular” and was told that her son was “not coping as well as before”.
Shortly after getting a scan, Yousef stopped breathing. “I was upset and suddenly there was a swarm of activity around Yousef.”
His condition continued to deteriorate. “It was so hard to see our son in pain. I felt useless and couldn’t do anything for him,” Al-Kharboush said. “It’s the worst experience a parent can have.”
The inquest heard how Yousef improved somewhat after being given antibiotics and taken to see his twin brother, but that this would be “the only time” he saw his brother.
But later his mother noticed he had no color and spots on his chest. “I wanted to stop his pain,” she said. “I took him in my arms while he was on a ventilator, I told them to remove him in the hope that this last chance to breathe on his own would be successful.”
Oscar Barker died in June 2014 in a separate hospital from multi-organ failure. Like Yousef, he and his twin brother were born prematurely. His mother, Hollie Barker, told the inquest that she realised something was wrong after being told that “Oscar had had a bad night”.
Barker told the court that a consultant had told her that bacteria had been found on the liquid baby formula, total parenteral nutrition (TPN), that Oscar had been feeding. She said: “At one point the hospital told me that the bacteria that had been found on the TPN was very unusual and that is where they think the bacteria came from, from outside the hospital.”
In September 2014, the Medicines and Healthcare products Regulatory Agency carried out four inspections of ITH Pharma’s manufacturing facilities and suggested that this was an isolated incident and that measures had been taken to prevent recurrence, the inquiry heard. A recall had also been ordered.
Aviva Otte also died in January 2014 at St. Thomas Hospital from liquid TPN contaminated with Bacillus cereus. At the time, St. Thomas’ TPN was manufactured in-house and the next supplier of TPN, ITH Pharma, did not manufacture the batch that killed Aviva.
ITH Pharma, which supplied TPN, was fined £1.2 million by a court in 2022 after it supplied TPN that infected 19 premature babies at nine hospitals in 2014.
An ITH Pharma spokesperson said after Monday’s hearing: “We express our deepest condolences to the families affected by the events of 2014.
“We are committed to supporting the coroner to ensure that the wider circumstances surrounding these three deaths are fully investigated.”
The investigation, which will last three weeks, will resume on Tuesday.