A leading NHS hospital failed to publicly disclose that four very ill premature babies in its care were infected with a deadly bacterium, one of whom died soon after, the Guardian can reveal.
St Thomas’ hospital did not admit publicly that it had suffered an outbreak of Bacillus cereus in the neonatal intensive care unit (NICU) of its Evelina children’s hospital in late 2013 and early 2014.
It occurred six months before a well publicised similar incident in June 2014 in which 19 premature babies at nine hospitals in England became infected with it after receiving contaminated baby feed directly into their bloodstream. Three of them died, including two at St Thomas’.
Leaked documents show that both the first outbreak and newborn baby’s death were investigated but never publicly acknowledged by the NHS trust that runs the hospital.
Internal papers from Guy’s and St Thomas’ trust (GSTT) in London, which runs the Evelina, show that it:
Did not acknowledge either the incident or infant’s death in any public forum.
Failed to mention the death in the report of its own internal inquiry into the outbreak.
Did not tell its own board that one of the four infected children who were given contaminated total parenteral nutrition (TPN) died, despite the board’s legal duty to oversee the trust.
Did not alert the media to the outbreak and instead prepared a statement in case it received any inquiries – none of which arrived, because GSTT never publicly acknowledged the incident.
GSTT insists that it did not acknowledge the baby’s death publicly in any reports because it believed the child had died of other medical conditions, not the bacteria. However, it declined to say if it had told the baby’s parents that it had become infected with Bacillus cereus.
The trust said that the child died on 2 January 2014, but did not disclose if it was a boy or a girl.
Rob Behrens, the parliamentary and health service ombudsman, criticised the trust for its failure to be open.
“St Thomas’ have a duty of candour and I am concerned that it may have fallen short here. Secrecy and lack of transparency have no place in the NHS. Patient safety cannot thrive where there is such a culture.”
He urged the parents of the unnamed child who died to contact him and let him know if they believed the events surrounding their child’s death needed to be investigated.
The Guardian’s disclosure comes soon after Jeremy Hunt, the former health secretary, used his new book Zero to lambast a “rogue system” in the NHS, where a repeated failure to be transparent about patient safety failings is a “major structural problem”.
GSTT’s “root cause analysis”, a 21-page report of its inquiry into the outbreak, said that the incident began in its NICU on 24 December 2013 and involved “extraordinarily high levels of contamination” with Bacillus cereus, which can cause sepsis.
But the report did not mention the newborn’s death. In a short section headed “Effect on patient”, it only says: “Four patients: three were felt to have moderate clinical deterioration, requiring increased respiratory support and a week of IV [intravenous] antibiotics. Moderate harm but no ongoing sequelae [after-effects of a disease, condition, or injury].”
In addition, GSTT’s board was not told of the death when the trust’s infection control committee presented its annual report to it in April 2014. The committee devoted just one short paragraph in its 14-page report to the incident. In its sole reference to the impact on patients, it said only that “In December four babies in NICU/SCBU [neonatal intensive care unit/special care baby unit] were identified with Bacillus cereus bacteraemia.”
GSTT maintained that it did not mention the death in either of the reports because it judged that it was due to the child’s poor underlying condition and premature birth and not the infection.
However, a third GSTT document casts doubt on the trust’s explanation. The minutes of a meeting of NICU staff and other trust personnel on 2 June 2014 to discuss the then ongoing second outbreak show a comparison was made between the still-undisclosed death of the baby in January to one that had just occurred.
The minutes say: “In the first outbreak earlier this year – baby that died had unexpected incidental haemorrhage and the baby that died here had a similar findings but needs 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 firm called ITH Pharma.
A spokesperson for ITH Pharma said: “ITH was not told of the previous outbreak of Bacillus cereus and death at St Thomas’ at any point prior to the summer 2014 incident. This is deeply troubling given that this appears to be the very reason we were brought in to supply TPN at St Thomas’.
“Any information about known increased risks as a result of a previous outbreak would have been of real value in taking steps to prevent future possible incidents. As it was, we were not told and a second incident occurred.”
ITH supplied the TPN that led to the 19 newborns becoming infected in June 2014. In April it was fined £1.2m for supplying the contaminated feed involved.
Officials at GSTT privately deny a cover-up. One said: “We were open and honest about the Bacillus cereus outbreak”. The trust is understood to have reported the death to the regional child death overview panel and involved Public Health England in its investigation into the outbreak.
A spokesperson for Guy’s and St Thomas’ said: “Very sadly, a baby died in our neonatal unit in early January 2014, following extensive health complications related to them being born very premature. While the baby tested positive for Bacillus cereus, their death was considered to be caused by other medical conditions.
“The safety of our patients is our absolute priority at Guy’s and St Thomas’ and we will always take immediate and comprehensive action any and every time this may be compromised, including alerting all the appropriate authorities and involving patients and their families.”
