Baby deaths from virus spread could have been prevented – BBC News

Two babies have died in a hospital’s neonatal intensive care unit in a preventable bacterial outbreak, the BBC has learned.

An internal investigation by Bradford Royal Infirmary (BRI) has found that poor hygiene practices allowed the spread of drug-resistant bacteria.

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

Bradford Teaching Hospitals NHS Trust said it had implemented new infection control measures, provided additional training and increased staffing levels.

A nurse who previously worked in the neonatal unit told the BBC that staff faced “extremely distressing” conditions which led to “medical errors”.

The agency’s internal investigation into the outbreak found there was a “missed opportunity” to provide the most appropriate antibiotics to two-week-old Harris – not his real name – when he first fell ill.

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

The babies who died were both born several months prematurely and were being treated in the same room of the neonatal unit at the time of the outbreak.

On November 10, one of the babies was found to have sepsis – a potentially fatal blood infection – caused by Klebsiella pneumoniae. But due to insufficient staffing levels, it was “deemed clinically unsafe” to place the infant in isolation, as would normally be expected, the report said. The baby died on November 12.

During a routine examination three days later, Harris was also found to have been infected with the bacteria. 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 he was fine and then suddenly he was gone.

“When it came to his burial, I kept thinking that he was in the best place and had received the best care.”

Klebsiella pneumoniae is a common bacteria that lives in the intestines and is usually harmless.

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

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

The World Health Organization (WHO) has expressed “great concern” about drug-resistant bacteria such as Klebsiella, warning that these so-called superbugs pose “a major threat to global health”.

The number of Klebsiella infections is rising in UK hospitals – with 11,823 cases recorded by NHS facilities in 2022-23, a 3% increase on the previous year, according to data from the UK Health Security Agency.

Sarah, from Bradford, was just 22 weeks pregnant when she went into labour with Harris.

“My husband and I thought we were going to lose the baby, we were terrified,” said Sarah, who was 25 at the time.

But despite being born four months premature, Harris appeared healthy and BRI doctors had no major concerns about him until he became ill about a week after his birth.

Doctors told the parents that the baby sleeping in the next crib had died of an infection that had been passed on to Harris.

Sarah said she had never heard of Klebsiella before, adding: “It was horrible to read about it, I realised it was passed from baby to baby and I didn’t understand how.”

Over the next few days, Harris’ health deteriorated and he died in his mother’s arms as she rocked him for the first time.

Sarah said: “I never expected to go to hospital, give birth to a baby and take him home to bury him.”

Four months after Harris’ death, the NHS report on his death arrived on his parents’ doorstep.

An investigation found that neonatal unit staff were not “consistently” following hand hygiene guidelines at the time of the outbreak and “did not appear to know” where and when personal protective equipment was required.

The report also said there was a “missed opportunity to make an earlier change” to Harris’ antibiotic treatment because the detection of Klebsiella pneumoniae in the unit was not reported.

Five other infants were diagnosed with the strain during the outbreak, forcing the hospital to temporarily close the unit to new admissions, but none required treatment.

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

“My heart broke for the family to know that if these simple changes could have been made, the baby might be with them now,” she added.

Sarah, who has brought a medical negligence claim against the NHS, said: “I hope BRI will learn from this case and ensure this never happens again.”

The two babies who died in November 2021 were not the first that year to lose their lives after being infected with Klebsiella at BRI.

Seven months earlier, in April, another baby died after being infected with a different strain of the bacteria.

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

“It surprises and disappoints me because if you look at the April report, there is no mention of improvement in infection prevention and control practices,” he said.

Professor Walsh, who has studied drug-resistant superbugs for 25 years, said there should have been “intensive sampling and staff should have been more vigilant” after the bacteria were first detected in November 2021.

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

She told the BBC: “While I was working there the conditions were extremely harsh, the staff I worked with were working extremely long hours, they were not able to take regular breaks and this led to fatigue which led to unintentional medical errors.

“You know, nurses know that good handwashing technique is important, but if you’re overloaded with work, it becomes really difficult.”

She added: “In neonatal intensive care, the ratio should be one baby to one nurse, but sometimes it’s three babies to one nurse or two babies to one nurse. I would go to work anxiously wondering, ‘Am I going to have the support I need to provide the right level of care?’”

Bradford University Hospitals declined to answer questions from the BBC about staffing levels in the neonatal intensive care unit and the number of deaths linked to infections at the hospital.

A spokesperson for the association offered its “sincere condolences to the families affected by this sad loss”, and said it had put in place “additional infection prevention and control measures” and increased “staffing levels and training of neonatal nurses to provide intensive care”.

“A recent evaluation of our neonatal services by NHS England concluded that the service provides safe, high-quality care,” they added.

A spokesperson for the Department of Health and Social Care said: “Our deepest sympathies go out to the families affected by this tragic case.

“The government will deliver the biggest increase in NHS staffing in history, with more doctors, nurses and midwives to deliver the quality, safe care that patients and their families deserve.”

If you have more information about this story or would like to tell me about a similar experience, you can contact me at sabbiyah.pervez@bbc.co.uk