Deaths in babies caused by viruses could have been prevented

Two babies died in a hospital’s neonatal intensive care unit during a bacterial outbreak that could have been prevented, the BBC has learned.

An internal investigation by the Bradford Royal Infirmary (BRI) found that the spread of drug-resistant germs was due to poor hygiene.

Five other infants were found to have the same strain of Klebsiella pneumoniae during the outbreak in November 2021. The mother of a two-week-old boy who died said she felt “betrayed” by the hospital and has 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 there were exposed to “extremely stressful” conditions that led to “medical errors”.

The trust’s internal investigation into the outbreak concluded that an “opportunity had been missed” to provide two-week-old Harris (not his real name) with the most appropriate antibiotics when he first became ill.

A patient safety incident investigation report, shared internally in March 2022 and seen by the BBC, also said infection control measures that could have stopped the spread of Klebsiella were “not consistently implemented” by ward staff.

The deceased babies were both born several months prematurely and were being cared for in the same room in the neonatal unit at the time of the outbreak.

On Nov. 10, one of the babies was diagnosed with sepsis – a life-threatening blood infection – caused by Klebsiella pneumoniae. However, due to staff capacity, it was “deemed clinically unsafe” to move the baby into isolation, as would normally be expected, the report said. The baby died on Nov. 12.

During a routine examination three days later, Harris was also diagnosed with an infection 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’s gone.

“When it came to the funeral, all I could think was that he had been in the best place and had received the best care.”

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

However, if the virus reaches other parts of the body, such as the bloodstream, it can lead to serious infections such as pneumonia – especially in patients with weakened immune systems.

Some strains are showing increasing resistance to antibiotics that doctors commonly use to treat infections and can cause serious illness or death even in previously healthy people.

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

The number of Klebsiella infections in UK hospitals has increased – according to data from the UK Health Safety Authority, 11,823 cases were recorded by NHS trusts in 2022-23, 3% more than the previous year.

Sarah, from Bradford, was only 22 weeks pregnant when Harris went into labour.

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

But even though Harris was born four months premature, he appeared to be healthy and doctors at BRI were not particularly concerned about him until he became ill about a week after birth.

Doctors told his parents that the baby in the next bed had died from an infection that had been transmitted to Harris.

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

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

Sarah said: “I didn’t expect to go to hospital, give birth to a baby and then bring it home for the funeral.”

Four months after Harris’ death, the NHS Trust’s death report landed on his parents’ doorstep.

According to an investigation, neonatal unit staff did not “consistently” follow hand hygiene guidelines at the time of the outbreak and it “appeared unclear” where and when personal protective equipment was required.

The report also said that “the opportunity to make earlier changes to Harris’ antibiotic therapy” was missed because the detection of Klebsiella pneumoniae on the ward was not communicated.

Five other infants were diagnosed with stress disorder during the outbreak, forcing the hospital to temporarily close the unit to new admissions. However, none of them required treatment.

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

“It broke my heart for the family knowing that if these simple changes could have been made, the baby could be with them right now,” she added.

Sarah, who has filed a medical negligence claim against the NHS Trust, said: “I hope BRI learns from this and makes sure it never happens again.”

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

Seven months earlier, in April, another baby had died as a result of an infection with a different strain of bacteria.

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

“This surprises and disappoints me because the April report does not mention any improvement in infection prevention and control,” he said.

Prof Walsh, who has been researching drug-resistant superbugs for 25 years, said there “should have been intensive swab testing and staff should have been more vigilant” after the bacteria were first discovered 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 stressful. The staff I worked with were working extremely long hours and were unable to take regular breaks. This led to exhaustion and, as a result, unintentional medical errors.”

“Nurses know that proper handwashing technique is important, but when you’re overworked, it becomes really difficult.”

She added: “In the neonatal intensive care unit, there should be a ratio of one baby to one nurse, but sometimes it’s three babies to one nurse or two babies to one nurse. I went to work nervous, thinking, ‘Will I have the adequate support I need to provide the appropriate care?'”

Bradford Teaching Hospitals declined to answer BBC questions about staffing levels in the neonatal intensive care unit and the number of infection-related deaths at the hospital.

A spokesperson for the foundation expressed its sincere condolences to the affected families for their tragic loss and said it had taken “additional infection prevention and control measures” and “increased the staffing levels and training of neonatal intensive care staff.”

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

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

“The Government will deliver the biggest NHS workforce expansion in history, with more doctors, nurses and midwives to deliver the high quality, safe care that patients and their families deserve.”

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