NHS trust admits contaminated feed caused baby’s death after decade of denial

An NHS trust has admitted that a highly vulnerable baby died because of contaminated feed that it gave her, after denying that for more than a decade.

At an inquest on Tuesday, Guy’s and St Thomas’ trust said it had given Aviva Otte a nutritional product containing deadly bacteria in January 2014. It had previously insisted to her mother, a coroner and the Guardian on multiple occasions that she had died of natural causes.

The change in GSTT’s explanation of Aviva’s death came during the second day of an inquest into her death and the deaths of two other babies in a separate outbreak of Bacillus cereus five months later.

Giving evidence at Southwark coroner’s court in London, Dr Grenville Fox – a senior consultant neonatologist who worked in the neonatal unit where Aviva was treated – said that it was now his opinion that the parenteral nutrition she received was the main cause of her death.

His statement represents a significant U-turn by GSTT. It also raises questions about its conduct and honesty over the first outbreak of Bacillus cereus in late 2013 and early 2014, in which four babies including Aviva were infected, which the Guardian first revealed in June 2022.

Bacillus cereus is a potentially fatal bacterium that infects about 20-30 newborn babies a year in England, Wales and Northern Ireland. Aviva’s mother, Jedidajah Otte, is a journalist with the Guardian.

The other two deaths being probed at the inquest – of Oscar Barker and Yousef Al-Kharboush – occurred during the second outbreak, in June 2014, in which 19 babies at nine different hospitals in England were infected after receiving contaminated liquid food. Three of them died.

Until this week’s inquest the trust had insisted that Aviva died as a result of being born very premature at just 24 weeks and two days gestation and having a range of medical complications, including brain haemorrhages. Fox had previously agreed with that explanation.

But he told the coroner, Dr Julian Morris: “Now my analysis is … with a very detailed and forensic examination of all of the details of the case, and an extensive literature search, I would conclude differently and my conclusion is that she did have an infection with Bacillus cereus, and that caused her deterioration on 1 January 2014.

“My conclusions are very different now than they were in 2014.”

Fox underlined his change of opinion in a written statement he gave to the coroner. He said: “In my opinion, the likely cause of death was massive intracranial haemorrhage likely secondary to Bacillus cereus encephalomeningitis due to parenteral nutrition containing Bacillus cereus, with contributory factors of extreme preterm birth at 24 weeks gestation, extremely low birth weight (560g) and recent surgery for necrotising enterocolitis.

“In my opinion it is likely that AO became infected as a result of receiving PN containing Bacillus cereus.”

At the time of the outbreak that claimed Aviva’s life, GSTT was making the parenteral nutrition provided to premature or very low birth-weight babies in the neonatal unit of its Evelina children’s hospital. After that, it outsourced the supply of the product to the pharmaceutical firm ITH Pharma, but did not tell them about the outbreak, in which four babies were affected.

ITH provided the contaminated food that infected the 19 babies in the second outbreak and in 2022 was fined £1.2m after pleading guilty to three charges related to it.

Dr Anthony Kaiser, a retired consultant neonatologist who was at GSTT in 2014 and treated Yousef Al-Kharboush, told the inquest on Tuesday that it was “not a cover up” under questioning by Clodagh Bradley KC, counsel for ITH Pharma.

Pressed on why he had not mentioned, in three separate statements in 2014 and 2015 to police investigating the second outbreak, that a very similar incident had happened five months beforehand, Kaiser denied misleading anyone or being selective in his evidence.

The inquest is expected to last for three weeks.