A leading NHS hospital has not publicly disclosed that four very ill premature babies in its care were infected with deadly bacteria, one of whom died shortly after, the Guardian can reveal.
St Thomas’ Hospital has not publicly admitted that it suffered an outbreak of Bacillus cereus in the neonatal intensive care unit (NICU) at her Evelina Children’s Hospital in late 2013 and early 2014.
It happened six months before a similar high-profile incident in June 2014 in which 19 premature babies in nine hospitals in England were infected with it after receiving contaminated baby food directly into their bloodstream. Three of them died, two of them in St Thomas.
Leaked documents show the first outbreak and the newborn’s death were investigated but never publicly acknowledged by the NHS trust that runs the hospital.
Internal documents from the Guy’s and St Thomas’ trust (GSTT) in London, which operates the Evelina, show that it:
GSTT insists it has not publicly acknowledged the baby’s death in any report, as it believes the child died of other medical conditions, not the bacteria. However, he declined to say whether he told the baby’s parents he had been infected with Bacillus cereus.
The trust said the child died on January 2, 2014, but did not disclose whether it was a boy or a girl.
Rob Behrens, the Parliament and Health Services ombudsman, criticized the trust for its failure to be open.
“St Thomas has a duty of candor and I fear it has fallen short here. Secrecy and transparency have no place in the NHS. Patient safety cannot thrive where there is such a culture.
He urged the parents of the unnamed deceased child to contact him and let him know if they believe the events surrounding their child’s death should be investigated.
The Guardian disclosure comes shortly after Jeremy Hunt, the former health secretary, used his new book Zero to castigate a ‘rogue system’ in the NHS, where a repeated lack of transparency over safety breaches of patients is a “major structural problem”.
GSTT’s “Root Cause Analysis”, a 21-page report on its outbreak investigation, said the incident began at its NICU on December 24, 2013 and involved “extraordinarily high levels of contamination” with Bacillus cereuswhich can cause sepsis.
But the report does not mention the death of the newborn. In a short section titled “Patient Effect”, it only states: “Four patients: three had moderate clinical deterioration, requiring increased respiratory support and one week of intravenous infusion. [intravenous] antibiotics. Moderate damage but no persistent sequelae [after-effects of a disease, condition, or injury].”
Further, the GSTT board was not made aware of the death when the trust’s infection control committee presented its annual report to it in April 2014. The committee devoted only a short paragraph in his 14-page report to the incident. In his only reference to the impact on patients, he only stated that “As of December, four babies in NICU/SCBU [neonatal intensive care unit/special care baby unit] have been identified with Bacillus cereus bacteremia”.
GSTT maintained that it did not mention the death in any of the reports as it believed it was due to the poor underlying condition and premature birth of the child and not the infection.
However, a third GSTT document casts doubt on the trust’s explanation. Minutes of a meeting of NICU staff and other trusted personnel on June 2, 2014 to discuss the then-ongoing second outbreak show that a comparison was made between the still undisclosed death of the baby in January and the one that had just happened.
The minutes read: ‘In the first outbreak earlier this year – the baby who died had an unexpected accidental haemorrhage and the baby who died here had similar findings but requires further investigation.’
GSTT responded to the outbreak by closing its in-house TPN production unit based in its pharmacy and outsourcing the supply of the product to a private company called ITH Pharma.
A spokesperson for ITH Pharma said: “ITH has not been made aware of the previous outbreak of Bacillus cereus and death in St Thomas at any time prior to the incident in the summer of 2014. This is deeply troubling given that this appears to be the very reason we were brought in to provide TPN in St Thomas’.
“Any information about known increased risks following a previous outbreak would have been of real value in taking action to prevent possible future incidents. As it stands, we were not told and a second incident has occurred.
ITH supplied the TPN which led to the infection of the 19 newborn babies in June 2014. In April it was fined £1.2million for supplying the contaminated food concerned.
GSTT officials privately deny a cover-up. One said: “We have been open and honest about the Bacillus cereus outbreak.” The trust reportedly reported the death to the regional Child Death Review Board and involved Public Health England in its investigation into the outbreak.
A Guy’s and St Thomas’ spokesperson said: “Very sadly, a baby died in our neonatal unit in early January 2014, following serious health complications related to their very premature birth. While the baby tested positive for Bacillus cereustheir deaths were considered to be caused by other medical conditions.
“The safety of our patients is our top priority at Guy’s and St Thomas’ and we will always take immediate and comprehensive action whenever this may be compromised, including alerting all relevant authorities and involving patients and their families.”