A leading NHS hospital has failed to reveal publicly that four very ill premature babies being cared for have been infected with a deadly bacterium, one of whom died shortly afterwards, the Guardian reports.
St. Thomas Hospital did not publicly acknowledge that it had an outbreak of Bacillus cereus in the Neonatal Intensive Care Unit (NICU) of Evelina Children’s Hospital in late 2013 and early 2014.
This happened six months before a well-publicized similar incident in June 2014, in which 19 premature babies in nine hospitals in England became infected with it after receiving contaminated baby food directly in their blood. Three of them died, including two in St. Thomas.
Leaked documents show that both the first epidemic and the death of a newborn baby were investigated, but were never publicly acknowledged by the trust of the NHS, which runs the hospital.
Internal documents from the Guy and St. Thomas Trust (GSTT) in London, which runs Evelina, show that:
The GSTT insists it has not publicly acknowledged the baby’s death in any reports, as it believes the child died of other medical conditions than bacteria. However, he declined to say whether he had told the baby’s parents that he had contracted Bacillus cereus.
The trust announced that the child died on January 2, 2014, but did not reveal whether it was a boy or a girl.
Rob Behrens, the parliament’s ombudsman and health ombudsman, criticized the credibility as not being open.
“St. Thomas has a duty to be honest, and I’m worried he may have failed here. Secrecy and transparency have no place in the NHS. Patient safety cannot thrive where there is such a culture. “
He called on the parents of the deceased nameless child to contact him and inform him if they believe that the events surrounding their child’s death should be investigated.
The revelation of The Guardian comes shortly after Jeremy Hunt, a former health minister, used his new book Zero to criticize the NHS ‘fraud system’, where the repeated refusal to be transparent about patient safety gaps is a major structural issue. “.
The GSTT’s “root cause analysis,” a 21-page outbreak investigation report, said the incident began at the NICU on December 24, 2013, and involved “extremely high levels of contamination” with Bacillus cereus, which can cause sepsis.
But the report does not mention the death of the newborn. A short section entitled “Patient Effect” states only: “Four patients: three experienced moderate clinical deterioration requiring increased respiratory support and one week IV [intravenous] antibiotics. Moderate damage, but no lasting effects [after-effects of a disease, condition, or injury]”
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In addition, the GSTT board was not notified of the death when the Trust’s Infection Control Committee presented its annual report in April 2014. The committee devoted only one short 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 at NICU / SCBU [neonatal intensive care unit/special care baby unit] have been identified with Bacillus cereus bacteriemia.
The GSTT maintains that it does not mention death in any of the reports, as it considers that it is due to the child’s poor basic condition and premature birth and not to the infection.
However, a third GSTT document calls into question the explanation for the trust. The minutes of a meeting of NICU staff and other trust staff on June 2, 2014 to discuss the ongoing second outbreak show that a comparison has been made between the still undiscovered death of the baby in January and the one that has just occurred.
The report said: “At the first outbreak earlier this year – the deceased baby had an unexpected accidental hemorrhage and the baby who died here had similar findings, but needs further investigation.
GSTT responded to the epidemic by closing its in-house TPN production unit based on its pharmacy and outsourcing the product to a private company called ITH Pharma.
A spokesman for ITH Pharma said: “ITH was not told about the previous outbreak of Bacillus cereus and death in St. Thomas at any time before the incident in the summer of 2014. This is deeply worrying, given that this seems to be the reason which is why we were attracted to deliver TPN to St Thomas’.
“Any information on known increased risks as a result of a previous outbreak would be of real value in taking steps to prevent possible future incidents. As it was, we were not told and a second incident occurred. “
ITH delivered TPN, which infected 19 newborns in June 2014. A £ 1.2 million fine was fined in April for delivering contaminated food.
GSTT officials deny private cover-up. One said, “We were open and honest about the outbreak of Bacillus cereus.” The trust is believed to have announced the death of the regional child death review panel and has involved public health in England in the investigation of the outbreak.
A spokesman for Guy’s and St. Thomas said: “Very sad, a baby died in our neonatology ward in early January 2014, after extensive health complications related to their birth very prematurely. Although the baby’s test was positive for Bacillus cereus, it is believed that their death was 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 can be compromised, including alerting all relevant authorities and involving patients and their families.
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