A mother whose premature baby died in hospital after receiving contaminated intravenous food has told her son’s inquest it was “the worst experience a parent could have”.
Yousef Al-Kharboush was nine days old when he died at St Thomas’ hospital in London on 1 June 2014 after developing sepsis from liquid food infected with bacteria called Bacillus cereus.
He was one of 19 premature babies who became infected in a major outbreak across nine hospitals in 2014.
The inquests into Yousef’s death, as well as those into two other babies who died in separate outbreaks involving contaminated feed – one-month-old Oscar Barker, who also died in June 2014, and three-month-old Aviva Otte, who died in January 2014 – began on Monday at Southwark coroner’s court.
The senior coroner, Dr Julian Morris, said his role was not to find blame but to identify the babies and how they died. The coroner revealed he was thinking of taking the unusual step of issuing a prevention of future deaths notice, a legal warning to one or more public or private bodies that they should take specific action to avoid any more deaths occurring in similar circumstances. Morris said: “The other duty I have to consider is whether to provide a prevention of future death report – that’s something I will consider as we hear the evidence over the next couple of weeks.”
Yousef and his twin brother were born at 32 weeks’ gestation by emergency caesarean section at St Thomas’ after their mother, Ghanda Al-Kharboush, was told that one of the babies was not growing properly.
Although both twins were fed intravenously while in intensive care, only Yousef died.
In a statement read out to the court, Al-Kharboush, said she realised Yousef was struggling when she went to express milk for him on 30 May 2014.
She spoke to a nurse about how “Yousef was not as noisy as normal” and his “breathing did not seem regular” and was told her son was “not coping as well as he had been”.
Shortly after receiving a scan, Yousef stopped breathing. “I was distraught and all of a sudden there was a hive of activity around Yousef.”
His condition continued to deteriorate. “It was so hard to see our son in pain. I felt useless and could do nothing for him,” Al-Kharboush said. “It is the worst experience that a parent could have.”
The inquest heard how Yousef rallied a little after receiving antibiotics and was taken to see his twin but that “this would be the only time” he saw his brother.
But later his mother noticed he had no colour and blotches on his chest. “I wanted to stop his pain,” she said. “I took him in my arms while attached to the ventilator, I told them to remove it in the hope that this one last chance to breathe unaided might prove successful.”
Oscar Barker died at another hospital in June 2014 from multiple organ failure. Like Yousef, he and his twin were born prematurely. His mother, Hollie Barker, told the inquest that she realised something was wrong after being told “Oscar had a bad night”.
Barker told the court that a consultant had told her that a bug had been found on the liquid baby food, total parenteral nutrition (TPN), that had been feeding Oscar. She said: “At some point the hospital told me that the bug found on the TPN was very unusual and that’s where they believe that the bug had originated, from outside the hospital.”
By September 2014, the Medicines and Healthcare products Regulatory Agency had carried out four inspections of ITH Pharma’s manufacturing facilities and suggested this had been an isolated incident and action had been taken to avoid a recurrence, the inquest heard. A recall had also been ordered.
Aviva Otte also died at St Thomas’ hospital from liquid TPN contaminated with Bacillus cereus in January 2014. At that time, St Thomas’s TPN was produced in-house and its subsequent provider of TPN, ITH Pharma, did not produce the batch that killed Aviva.
ITH Pharma, which provided TPN, was fined £1.2m by a crown court in 2022 after providing TPN from which 19 premature babies became infected across nine hospitals in 2014.
An ITH Pharma spokesperson said after Monday’s hearing: “We offer our deepest sympathies to the families affected by the events of 2014.
“We are committed to assisting the coroner to ensure that the wider circumstances of these three deaths are fully investigated.”
The inquest, due to last three weeks, resumes on Tuesday.
