A leading NHS hospital has failed to publicly disclose that four very sick premature babies in its care have contracted the deadly germ, one of whom died soon after, according to the Guardian.
St Thomas’ Hospital has not publicly acknowledged that it suffered from the outbreak Sirius bacilli bacteria In the neonatal intensive care unit (NICU) at Evelina Children’s Hospital in late 2013 and early 2014.
It happened six months before a similar well-publicized incident in June 2014 in which 19 premature babies in nine hospitals in England contracted it after receiving contaminated infant formula directly into their bloodstream. Three of them died, including two at St. Thomas.
Leaked documents show that both the first outbreak and the newborn’s death have been investigated, but have not been publicly acknowledged by the NHS trust that runs the hospital.
Internal papers from Guy’s and St Thomas’ Trust (GSTT) in London, which operates Evelina, show that:
The GSTT insists it has not publicly acknowledged the child’s death in any reports because it believes the child died from other medical conditions, not bacteria. However, she refused to say whether she had informed the child’s parents that she had contracted the infection Sirius bacilli bacteria.
The secretariat said that the child died on January 2, 2014, but did not disclose whether it was a boy or a girl.
Rob Burns, Parliamentary Ombudsman and Health Services, criticized the trust for failing to open up.
“St Thomas has a duty of honesty and I worry he may have failed here. Secrecy and transparency have no place in the NHS. Patient safety cannot thrive where such a culture exists.”
He urged the parents of the unnamed child who died to contact him and inform him if they believe the events surrounding their child’s death need to be investigated.
The Guardian revelations come shortly after Jeremy Hunt, the former health minister, used his new book Zero to criticize a “rogue system” in the NHS, where repeated failures to be transparent about patient safety failures are a “major structural problem”.
The GSTT’s “root cause analysis”, a 21-page report on its investigation into the outbreak, said the accident began in a neonatal intensive care unit on December 24, 2013 and included “unusually high levels of contamination.” Sirius bacilli bacteriawhich can cause sepsis.
But the report did not mention the death of the newborn. In a short section titled “The Impact on the Patient,” he says only: “Four patients: three experienced moderate clinical deterioration, requiring increased respiratory support and a week of intravenous administration.” [intravenous] Antibiotics. Moderate damage but no persistent sequelae [after-effects of a disease, condition, or injury]. “
In addition, the GSTT Board was not informed of the death when the fund’s infection control committee submitted its annual report to it in April 2014. The committee devoted only one short paragraph in its 14-page report to the incident. In one reference to the effect on patients, she only said that “in December there were four children in the NICU/SCBU [neonatal intensive care unit/special care baby unit] identified with Sirius bacilli bacteria Bleeding”.
The GSTT asserted that it did not mention the death in either report because it considered that it was due to the baby’s poor underlying condition and premature birth rather than infection.
However, a third GSTT document casts doubt on the interpretation of the trust. Minutes of a June 2, 2014 meeting of NICU and other trust staff to discuss the second ongoing outbreak, show that a comparison was made between the undisclosed death of the infant in January and the death that had just occurred.
The record says: “At the first outbreak of the epidemic earlier this year – the child who died had unexpected accidental bleeding and the child who died here had similar results but needs further investigation.”
GSTT responded to the outbreak by shutting down its in-house TPN production unit and outsourcing the supply of the product to a private company called ITH Pharma.
An ITH Pharma spokesperson said: “ITH has not been informed of the previous outbreak Sirius bacilli bacteria and death in St Thomas anytime prior to the summer 2014 incident. This is very concerning given that it appears to be the real reason we were brought in to supply the TPN in St Thomas.
“Any information about the known increased risks as a result of a previous outbreak would have been of real value in taking steps to prevent potential accidents in the future. As it was, we were not told and a second incident occurred.”
ITH supplied TPN which resulted in 19 newborns infected in June 2014. In April it was fined £1.2m for supplying the contaminated feed in question.
GSTT officials secretly deny the cover-up. One said: “We were open and honest about Sirius bacilli bacteria Outbreak.” The trust is understood to have reported the death of the Regional Child Mortality Overview panel and involved Public Health England in its investigation into the outbreak.
A Guy’s and St Thomas spokesperson said: “Unfortunately, a baby died in our neonatal unit in early January 2014, after extensive health complications related to a very premature birth. While the baby tested positive, the baby tested positive for Sirius bacilli bacteriaTheir deaths were considered to be due to other medical conditions.
“The safety of our patients is our absolute priority at Guy’s and St Thomas, and we will always take prompt and thorough action any and time this may be at risk, including alerting all relevant authorities and engaging patients and their families.”