After more than a decade of denials, the UK's National Health Service (NHS) has admitted that extremely vulnerable babies died from contaminated nutrition given by the service.
Guy's and St Thomas' Trust told an inquest on Tuesday that it gave Aviva Otte a nutritional supplement containing the deadly bacteria in January 2014. The trust had previously repeatedly insisted to her mother, the coroner and the Guardian that she had died of natural causes.
The change in the GSTT's explanation for Aviva's death came on the second day of an inquest into her death and the deaths of two other infants from separate infection outbreaks. Bacillus cereus Five months later.
Giving evidence at Southwark Coroner's Court in London, Dr Grenville Fox – a senior neonatologist who worked in the neonatal unit where Aviva was treated – said he now believed the enteral feeding she received was the primary cause of her death.
His comments represent a significant change of policy for GSTT and also raise questions about its actions and sincerity in responding to the initial outbreak. Bacillus cereus The case was first reported by The Guardian in June 2022, when four infants, including Aviva, were infected between late 2013 and early 2014.
Bacillus cereus Aviva's mother, Jedidaja Otte, is a journalist for The Guardian.
The other two deaths being investigated at the inquest, Oscar Barker and Yousef Al Karbouche, died during a second outbreak in June 2014, when 19 babies in nine hospitals in England became infected after consuming contaminated liquid food. Three of them died.
Until this week's inquest, the trust had maintained that Aviva was born prematurely at 24 weeks and two days and died as a result of a range of complications, including a brain haemorrhage – an explanation that Mr Fox had previously agreed with.
But he told coroner Dr Julian Morris: “My analysis … after a very detailed forensic examination of all the details of the case and after extensive literature research I have come to a different conclusion. My conclusion is that she did indeed have an infection. Bacillus cereuswhich led to a deterioration in her condition on January 1, 2014.
“My conclusions are very different now than they were in 2014.”
Mr Fox emphasised his change of opinion in a written submission to the coroner: “In my opinion the cause of death was massive intracranial haemorrhage, probably due to a stroke.” Bacillus cereus encephalopathy Included in enteral nutrition formulas Bacillus cereusExtremely preterm birth at 24 weeks' gestation, extremely low birth weight (560 g), and recent surgery for necrotizing enterocolitis were contributing factors.
“In my opinion, AO most likely became infected as a result of ingesting PN. Bacillus cereus.”
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At the time of the outbreak that took Aviva's life, GSTT was manufacturing parenteral nutrition products for premature and very low birth weight babies in the neonatology department at Evelina Children's Hospital. The company then outsourced the supply of its products to pharmaceutical company ITH Pharma, but did not inform the company about the outbreak that infected four babies.
ITH supplied the tainted food which infected 19 infants in the second outbreak and pleaded guilty to three related charges in 2022 and was fined £1.2 million.
Dr Anthony Kaiser, a former consultant neonatologist who worked at GSTT in 2014 and treated Yousef Al Karbouche, told the inquest on Tuesday “it was not a cover-up”, when questioned by ITH Pharma's lawyer Clodagh Bradley KC.
Asked why he failed to mention a very similar incident that had occurred five months earlier in three separate statements he made to police investigating the second outbreak in 2014 and 2015, Kaiser denied misleading anyone or cherry-picking testimony.
The inquest is expected to last three weeks.
