A major NHS hospital has not publicly disclosed that four very sick premature babies in its care were infected with a deadly bacteria, one of whom died soon after, the Guardian can reveal.
St Thomas hospital has not publicly admitted to having suffered an outbreak of bacillus cereus in the neonatal intensive care unit (NICU) of her Evelina children’s hospital in late 2013 and early 2014.
It came six months before a similar well-publicized incident in June 2014, in which 19 premature babies in nine hospitals in England were infected with it after receiving contaminated food directly into their bloodstream. Three of them died, including two in St Thomas’.
Leaked documents show that both the first outbreak and the newborn baby’s death were investigated but never publicly acknowledged by the NHS fund that runs the hospital.
Internal documents from Guy’s and St Thomas’ Trust (GSTT) in London, which manages Evelina, show that:
The GSTT insists it did not publicly acknowledge the baby’s death in any reports because it believed the child had died of medical conditions other than the bacteria. However, he declined to say whether he had told the baby’s parents that 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, parliamentary and health service ombudsman, criticized the trust for not being open.
“Saint Thomas has a duty of frankness and I am concerned that he may have fallen short here. Secrecy and transparency have no place on the NHS. Patient safety cannot thrive where that culture exists.”
He asked the parents of the unnamed child who died to contact him and let him know if they believed the events surrounding their son’s death needed to be investigated.
The Guardian’s disclosure comes shortly after Jeremy Hunt, a former health secretary, used his new book Zero to criticize a “rogue system” on the NHS, where a repeated failure to be transparent about patient safety flaws is a “big structural problem”.
The GSTT’s “root cause analysis”, a 21-page report of its investigation into the outbreak, said the incident began in its NICU on December 24, 2013 and involved “extraordinarily high levels of contamination” with bacillus cereuswhich can cause sepsis.
But the report did not mention the newborn’s death. In a small section entitled “Effect on the patient”, it simply says: “Four patients: three had moderate clinical deterioration, requiring greater respiratory support and a week of [intravenous] antibiotics. Moderate damage, but no ongoing sequelae [after-effects of a disease, condition, or injury].”
Furthermore, the GSTT board was not informed of the death when the trust’s infection control committee submitted its annual report in April 2014. The committee devoted only a small paragraph in its 14-page report to the incident. In his only reference to the impact on patients, he said only that “in December, four babies in the NICU/SCBU [neonatal intensive care unit/special care baby unit] were identified with bacillus cereus bacteremia.”
The GSTT maintained that it did not mention the death in any of the reports because it judged that it was due to the child’s poor baseline condition and premature birth rather than the infection.
However, a third GSTT document casts doubt on the trust explanation. The minutes of a meeting of NICU staff and other trusted officials on June 2, 2014 to discuss the second outbreak in progress show that a comparison was made between the baby’s as-yet-unrevealed death in January with one that had just occurred.
The minutes read: “In the first outbreak earlier this year – the baby who died had unexpected incidental bleeding and the baby who died here had similar findings but needs further investigation.”
GSTT responded to the outbreak by closing its in-house TPN production facility based at its pharmacy and outsourcing the product supply to a private company called ITH Pharma.
A spokesperson for ITH Pharma said: “ITH was not informed of the previous outbreak of bacillus cereus and death at St Thomas’ at any point prior to the summer 2014 incident. This is deeply concerning, as this appears to be the reason why we were brought in to provide TPN at St Thomas’.
“Any information on known increased risks as a result of a previous outbreak would have been of real value in taking steps to prevent possible future incidents. As it was, we were not informed and a second incident occurred.”
ITH provided the TPN that led to the infection of the 19 newborns in June 2014. In April it was fined £1.2m for providing the contaminated feed involved.
GSTT officials 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: “Sadly, a baby died in our neonatal unit in early January 2014 following extensive health complications related to premature birth. While the baby tested positive for bacillus cereushis death was ruled 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 whenever this is compromised, including alerting all appropriate authorities and involving patients and their families.”