NHS trust admits contaminated food caused baby’s death after decade of denial

An NHS hospital has admitted that a highly vulnerable baby died after eating contaminated food it fed her, a claim it denied for more than a decade.

At an inquest on Tuesday, the Guy’s and St Thomas’ trust told a court it had fed Aviva Otte a food product containing deadly bacteria in January 2014. It had previously repeatedly insisted to her mother, a coroner and the Guardian that she had died of natural causes.

The change in GSTT’s explanation of Aviva’s death came on the second day of an investigation into her death and the deaths of two other babies in a separate outbreak of Bacillus cereus five months later.

Testifying at Southwark Coroner’s Court in London, Dr Grenville Fox, a senior neonatologist who worked in the neonatal unit where Aviva was treated, said he now believed the parenteral nutrition she was receiving was the main cause of her death.

His statement represents a significant U-turn by GSTT. It also raises questions about GSTT’s conduct and honesty during the initial outbreak of Bacillus cereus in late 2013 and early 2014, infecting four babies, including Aviva, which The Guardian first revealed in June 2022.

Bacillus cereus is a potentially deadly bacteria that infects around 20-30 newborn babies a year in England, Wales and Northern Ireland. Aviva’s mother, Jedidajah Otte, is a journalist at the Guardian.

The other two deaths being investigated by the inquest – those of Oscar Barker and Yousef Al-Kharboush – occurred during the second outbreak, in June 2014, when 19 babies in nine different hospitals in England were infected after being fed contaminated liquid food. Three of them died.

Until this week’s inquiry, the trust had maintained that Aviva died as a result of a very premature baby born at just 24 weeks and two days gestation and a series of medical complications, including brain haemorrhages. Fox had previously agreed with that explanation.

But he told the coroner, Dr Julian Morris: “Now my analysis… with a very detailed and forensic examination of all the details of the case, and an extensive literature review, I would conclude otherwise and my conclusion is that she did have an infection with Bacillus cereusand that caused her to deteriorate on January 1, 2014.

“My conclusions are now very different from those in 2014.”

Fox underlined his changed opinion in a written statement he gave to the coroner. He said: “In my opinion the probable cause of death was a massive intracranial haemorrhage, probably secondary to Bacillus cereus encephalomeningitis due to parenteral nutrition that Bacillus cereuswith contributing factors including extreme prematurity at 24 weeks of gestation, extremely low birth weight (560 g), and recent surgery for necrotizing enterocolitis.

“I think it is likely that AO became infected as a result of receiving PN with Bacillus cereus.”

At the time of the outbreak that claimed Aviva’s life, GSTT was making the parenteral nutrition given to premature and very low birth weight babies in the neonatal unit of the Evelina Children’s Hospital. It then outsourced the supply of the product to the pharmaceutical company ITH Pharma, but failed to tell them about the outbreak, which affected four babies.

ITH supplied the contaminated food that infected the 19 babies in the second outbreak. In 2022, the company was fined £1.2 million after pleading guilty to three charges related to it.

Dr Anthony Kaiser, a retired neonatologist who worked at GSTT in 2014 and treated Yousef Al-Kharboush, told the inquiry on Tuesday that there was “no cover-up”, under questioning from Clodagh Bradley KC, lawyer for ITH Pharma.

When asked why he had failed to mention in three separate statements in 2014 and 2015 to police investigating the second outbreak that a similar incident had occurred five months earlier, Kaiser denied misleading anyone or being selective in his evidence.

The investigation is expected to last three weeks.