Premature baby was one of three to die in 'contaminated' feed tragedy

A premature twin baby born at just 28 weeks was one of three who died after being given a 'contaminated' feeding solution, an inquest has found.

Oscar Barker, Aviva Otte, and Yousef Al-Kharboush all died in 2014 after being fed with a solution that had been contaminated by a bacterium called bacillus cereus.

The coroner has written a prevention of future deaths report, demanding action from public health bodies to avoid such a tragedy happening again.  

Oscar was born at the Rosie Hospital, Addenbrooke's in Cambridge on May 27, 2014, at 28 weeks gestation as one of twins. 

He was given total parenteral nutrition (TPN), which is a liquid solution containing nutrients to help children grow, according to Great Ormond Street Hospital.

His health was monitored and he underwent surgery and a blood transfusion. 

At 20 days after he was born, he was 'very sick' with multi-organ failure and sepsis. 

Blood cultures were tested and one was found to have bacillus cereus. Oscar died on June 29, 2014.

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Aviva and Yousef were both born premature at St Thomas' hospital and both were also one of a pair of twins.

Yousef died on June 1, 2014, aged eight days and Aviva died aged two months on January 2, 2014 - both had received TPN contaminated by bacillus cereus.

Following Aviva's death, Guy's and St Thomas' trust undertook a cause analysis in partnership with the UKHSA to try and establish the source of the bacterial outbreak, but none was found.

In June, both Oscar and Yousef died after contracting the same bacteria.

Guy's and St Thomas' trust only admitted Aviva had died following the contamination at the inquest, having repeatedly told her family over the past decade she had died from natural causes. 

The outbreak also affected other babies in other NHS trusts, but fortunately these babies recovered. 

The feed provided to Yousef and Oscar by ITH Pharma was being used by nine different hospitals across the UK between May and June 2014 and saw 17 more babies become ill.

ITH Pharma was fined £1.2million for regulatory offences following the deaths of Oscar and Yousaf.

Previously, a spokesman for ITH Pharma said: 'ITH was not told of the previous outbreak of Bacillus cereus and death at St Thomas' at any point prior to the summer 2014 incident.

'This is deeply troubling given that this appears to be the very reason we were brought in to supply TPN at St Thomas'.'

In 2022, ITH Pharma admitted failing to conduct a suitable and sufficient risk assessment between August 2009 and June 2014, and two charges of supplying a medicinal product which was not of the nature or quality specified in the prescription.

Regarding Aviva's death, Dr Morris wrote: 'The Trust undertook a root cause analysis together with involving the UKHSA and its own infection and microbiological teams, but no definitive source for the outbreak was found.'

He wrote that the hospital trust where she died had not passed on their findings to other places compounding TPN under a section 10 exemption, which allows pharmacists to make a limited quantity of medicine for a specific patient, or to the wider market.

A Prevention of Future Deaths report into the babies' deaths by senior coroner Dr Julian Morris has called on the Department of Health and Social Care, NHS England, Care Quality Commission, Medicines, and Healthcare Products Regulatory Agency (MHRA) to take action. 

The organisations must respond to the report by January 8, 2025.

The Prevention of Future Deaths report listed matters of concern including that there is no requirement for entities using the section 10 exemption to report findings to the MHRA or other bodies following an 'adverse event'. 

It added that current reporting structures are 'unclear' when sharing information would improve 'the provision of highly specific medication to a group of vulnerable patients'.