Bug-spread baby deaths ‘could have been prevented’

Two babies have died after a preventable bacterial infection broke out in the hospital’s neonatal intensive care unit, the BBC reports.

An internal investigation by Bradford Royal Infirmary (BRI) reported that poor hygiene practices had led to the spread of drug-resistant bacteria.

Five other infants were found to be infected with the same Klebsiella pneumoniae strain during the outbreak in November 2021. The mother of the two-week-old boy who died said she felt “betrayed” by the hospital and had launched legal action.

Bradford Teaching Hospitals NHS Trust said it had implemented new infection prevention measures, provided extra training and increased staff numbers.

A nurse who previously worked in the neonatal ward told BBC staff she faced extremely challenging conditions which led to “medical errors”.

The trust’s internal investigation into the outbreak found there was a “missed opportunity” to give two-week-old baby Harris (not his real name) the most appropriate antibiotic when he first fell ill.

The patient safety incident investigation report, circulated internally in March 2022 and seen by the BBC, also said infection control measures that would have stopped the spread of Klebsiella “were not consistently implemented by staff on the unit”.

Both infants who died were born several months premature and were being cared for in the same neonatal room at the time of the outbreak.

On November 10, one of the babies was found to have sepsis, a life-threatening blood infection, caused by Klebsiella pneumoniae. But because staff numbers were low, it was “deemed not clinically safe” to isolate the baby as would normally be expected, the report said. The baby died on November 12.

A routine test three days later revealed that Harris had also been infected with the bacteria, and he died of sepsis on November 21.

His mother, Sarah (not her real name), told the BBC: “It was a really, really difficult time. I couldn’t believe it because my son had been so happy and then suddenly he was gone.”

“When it came time for him to be buried, I just thought he was being buried in the best place, with the best care.”

Klebsiella pneumoniae is a common, normally harmless bacterium that lives in the intestines.

However, if it enters other parts of the body, such as the bloodstream, it can cause serious infections, including pneumonia, especially in patients with weakened immune systems.

Some strains are becoming increasingly resistant to antibiotics that doctors typically use to treat infections, and can cause severe illness or death in previously healthy people.

The World Health Organisation (WHO) said it was “very concerned” about drug-resistant bacteria such as Klebsiella, warning that so-called superbugs pose a “major global health threat”.

Data from the Health Security Agency shows the number of Klebsiella infections is rising in English hospitals, with 11,823 cases recorded by NHS trusts in 2022-23, a 3% increase on the previous year.

Sarah, from Bradford, was 22 weeks pregnant when she gave birth to Harris.

“My husband and I were terrified, thinking we would lose our baby,” said Sarah, who was 25 at the time.

But despite being born four months premature, Harris appeared healthy and doctors at BRI didn’t have any major concerns about him until he began feeling unwell about a week after his birth.

Doctors told the parents that a baby in an adjacent cot had died from an infection that was then transmitted to Harris.

Sarah said she had never heard of Klebsiella before, adding: “It was terrifying to read about it. I knew it could be transmitted from baby to baby but I didn’t understand how it was transmitted.”

Over the next few days, Harris’ health deteriorated and for the first time, Harris died in her mother’s arms.

“I never thought I’d go to the hospital, have a baby, and then take it home to be buried,” Sarah said.

Four months after Mr Harris died, the NHS Trust’s report into his death arrived on his parents’ doorstep.

The investigation found that staff on the neonatal unit did not “consistently” follow hand hygiene guidelines at the time of the outbreak and “appeared to have been unclear” about when and where personal protective equipment was needed.

The report also said the hospital was not informed that Klebsiella pneumoniae had been detected on the ward, resulting in a “missed opportunity to make earlier changes” to Mr Harris’ antibiotic treatment.

During the outbreak, five other infants were also found to have the bacteria in their bodies, forcing the hospital to temporarily close to new admissions, but none of them required treatment.

Hannah Lucy Delahode, a lawyer from Irwin Mitchell LLP who is representing the family, said she was “shocked and horrified” to see “everything that went wrong” and “how easy it would have been to prevent this baby’s death”.

“My heart breaks for the family, knowing that if they had been able to make those simple changes, their baby could have been with them right now,” she added.

Sarah, who has filed a malpractice lawsuit against the NHS trust, said: “I hope the BRI learns from this incident and ensures this never happens again.”

The two infants who died in November 2021 were not the first infants that year to lose their lives to Klebsiella infection at BRI.

Seven months earlier, in April, another baby died from a different strain of the bacteria.

Timothy Walsh, professor of medical microbiology at the University of Oxford, said lessons should have been learned from previous outbreaks.

“I was surprised and disappointed when I looked at the April report and saw no mention of improving infection prevention controls,” he said.

Prof Walsh, who has studied drug-resistant superbugs for 25 years, said after the bacteria was first detected in November 2021 “thorough testing should have been carried out and staff should have been more vigilant”.

A nurse who previously worked in the hospital’s neonatal intensive care unit said staff were tired and overworked.

She told the BBC: “When I worked there the environment was extremely demanding and the staff I worked with worked extremely long hours and were not able to take regular breaks which led to fatigue and therefore unintentional medical errors.”

“Nurses know the importance of proper hand-washing technique, but when they are overworked it becomes very difficult.”

She added: “In the neonatal intensive care unit, there should be one nurse to every baby, but sometimes there is one nurse to every three babies, or even one nurse to every two babies. I went to work feeling anxious, wondering: ‘Will I have enough support to provide the right level of care?'”

Bradford Teaching Hospitals refused to answer the BBC’s questions about staff numbers in its neonatal intensive care unit or the number of deaths from infection in the hospital.

A spokesman for the trust said: “Our deepest condolences go to the family who have suffered this tragic loss”, adding that it had taken “additional infection prevention and control measures” and “increased the staffing and training of neonatal nurses providing intensive care”.

“NHS England’s recent assurance review of its neonatal service concluded that the service provides safe, high-quality care,” they added.

A Department of Health and Social Care spokesman said: “Our sincere condolences go to the family affected by this tragic incident.”

“The Government will deliver the biggest ever increase to NHS staff, delivering more doctors, nurses and midwives to deliver the high-quality, safe care that patients and their families deserve.”

If you have any further information about this story or can share a similar experience, please contact us below. [email protected]