An NHS trust has acknowledged that a highly vulnerable baby died due to contaminated feed provided by them, after maintaining for more than ten years that her death was due to natural causes.
On Tuesday, during an inquest, Guy’s and St Thomas’ Trust admitted that in January 2014, it had administered a nutritional product tainted with deadly bacteria to Aviva Otte. Prior to this admission, the trust had repeatedly insisted to Aviva’s mother, the coroner, and the Guardian that her death was due to natural causes.
This shift in explanation emerged on the second day of the inquest into Aviva’s death and the deaths of two other babies from a separate Bacillus cereus outbreak five months later.
Dr. Grenville Fox, a senior consultant neonatologist at the neonatal unit where Aviva was treated, testified at Southwark Coroner’s Court in London. He now believes that the parenteral nutrition Aviva received was the primary cause of her death.
This new stance from Guy’s and St Thomas’ Trust represents a significant reversal from their previous position. It raises concerns about the trust’s transparency and handling of the initial Bacillus cereus outbreak, which affected four babies, including Aviva. The Guardian first reported on this outbreak in June 2022.
Bacillus cereus is a potentially deadly bacteria that affects approximately 20-30 newborns annually in England, Wales, and Northern Ireland. Aviva’s mother, Jedidajah Otte, is a journalist with the Guardian.
The inquest is also investigating the deaths of Oscar Barker and Yousef Al-Kharboush, which occurred during a second outbreak in June 2014. This outbreak infected 19 babies across nine hospitals in England with contaminated liquid food, resulting in three deaths.
Previously, the trust claimed that Aviva’s death was due to her extreme prematurity at just 24 weeks and various medical complications, including brain hemorrhages. Dr. Fox had supported this explanation until now.
Dr. Fox informed the coroner, Dr. Julian Morris, that after a thorough review of the case and related literature, he now concludes that Aviva’s death was caused by an infection with Bacillus cereus. He stated, “My conclusions have changed significantly since 2014.”
In a written statement, Dr. Fox detailed his revised opinion, attributing Aviva’s death to massive intracranial hemorrhage likely caused by Bacillus cereus encephalomeningitis from the contaminated parenteral nutrition. He noted that Aviva’s extreme prematurity, very low birth weight, and recent surgery contributed to her condition.
At the time of the outbreak, Guy’s and St Thomas’ Trust was producing the parenteral nutrition at its Evelina Children’s Hospital. The trust later outsourced the product supply to ITH Pharma but failed to inform them about the previous outbreak. ITH Pharma’s contaminated product was linked to the second outbreak, which led to a £1.2 million fine in 2022 for three related charges.
Dr. Anthony Kaiser, a retired consultant neonatologist who treated Yousef Al-Kharboush, testified that there was no cover-up, despite questions from Clodagh Bradley KC, counsel for ITH Pharma. Kaiser denied any intent to mislead or be selective in his statements to the police.
The inquest is expected to continue for three weeks.
