A MUM whose premature baby died in her arms after being given contaminated feed has told an inquest it was “the worst experience a parent could have”.
Ghanda Al-Kharboush’s son Yousef died in June 2014 at St Thomas’ Hospital in London after he developed sepsis.
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He and his twin brother were born by emergency Caesarean section at just 32 weeks in May 2014.
Yousef passed away at just nine days old, after Bacillus cereus bacteria infected his feed.
He was one of three babies who died after receiving contaminated feed around that time.
One-month-old Oscar Barker passed away in June that year, while three-month-old Aviva Otte died in January 2014.
A total of 19 babies were infected after having baby feed pumped into their bloodstream – because they were unable to feed on their own – between May 27 and June 2, 2014.
A inquest into the three babies’ deaths began at Southwark Coroner’s Court on September 9.
Senior coroner Dr Julian Morris said his role was not to find blame, but examine the evidence and “consider whether to provide a prevention of future death report”.
These are issued to people, organisations, local authorities, government departments or agencies when a coroner believes that action should be taken to prevent future deaths from happening in the same manner.
Ms Al-Kharboush – who had moved with her husband from Saudi Arabia to study for a PhD in dentistry – gave birth to her twin boys by emergency C-section at 32 weeks, after being that one of the babies was not growing properly.
Both were placed in intensive care at St Thomas Hospital and were fed intravenously – meaning they were given a liquid mixture of nutrients directly into their bloodstream, common practice when newborns are unable to eat on their own.
While Abdulilah was not affected, Yousef contracted lethal blood poisoning from the feed, which was contaminated with the bacteria bacillus cereus.
In a statement read out to the court, Ms Al-Kharboush said she had spotted something was wrong when she went to express milk for her child on May 30, 2014.
She spoke to a nurse after noticing “Yousef was not as noisy as normal” and his “breathing did not seem regular”.
Ms Al-Kharboush was told that Yousef was “not coping as well as he had been” and a scan was taken.
I wanted to stop his pain. I took him in my arms while attached to the ventilator
Ghanda Al-Kharboush
She added: “Shortly after the scan, Yousef stopped breathing. I was distraught and all of a sudden there was a hive of activity around Yousef.”
Ms Al-Kharboush watched as his condition deteriorated in the following days, adding: “It was so hard to see our son in pain. I felt useless and could do nothing for him.”
She said: “It is the worst experience that a parent could have.”
Yousef seemed to improve after being given antibiotics and he was taken to see his twin but “this would be the only time” he would meet his brother, the court heard.
Ms Al-Kharboush later noticed he had no colour and blotches on his chest.
She said: “I wanted to stop his pain.
“I took him in my arms while attached to the ventilator.”
Yousef passed away on June 1.
Contamination ‘wholly exceptional’
The inquest also heard about the death of one-month-old Oscar Barker, who was born early with his twin at Addenbrooke’s Hospital in Cambridge.
His mother Hollie Barker realised that something was wrong after being told “Oscar had a bad night” – he later died of multiple organ failure.
Ms Barker was told by a consultant that a bug had been found on the baby feed Oscar was being given, total parenteral nutrition (TPN).
She told the inquest: “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 (MHRA) had carried out four inspections into the baby feed’s producer, ITH Pharma.
After inspecting the company’s manufacturing facilities, it suggested this had been an isolated incident.
Action had been taken to avoid a recurrence and a recall of the feed had also been ordered, the inquest heard.
We are committed to assisting the coroner to ensure that the wider circumstances of these three deaths are fully investigated
Spokesperson
ITH Pharma was fined £1.2 million by a crown court in 2022 after its TPN was tied to the infection of 19 premature babies across nine hospitals in 2014.
An ITH Pharma spokesperson said in 2022 after sentencing: “We accept the fine imposed by the court, having pleaded guilty to a single regulatory offence of failing to have a suitable and sufficient risk assessment, under the Management of Health and Safety at Work Regulations 1999, and to two regulatory offences under the Medicines Act 1968 of supplying a medicinal product on 27 May 2014 not of the nature or quality specified in the prescription.”
It described those events as “wholly exceptional”, adding that the parenteral nutrition it had produced since 2008 had helped many tens of thousands of the most vulnerable babies survive premature and complex births.
What are the symptoms of sepsis?
SEPSIS is a life-threatening reaction to an infection that happens when your immune system overreacts and starts to damage your body’s own tissues and organs.
Symptoms of sepsis in an adult include:
- Acting confused, slurred speech or not making sense
- Blue, grey, pale or blotchy skin, lips or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
- A rash that does not fade when you roll a glass over it, the same as meningitis
- Difficulty breathing, breathlessness or breathing very fast
Symptoms in a child include:
- Blue, grey, pale or blotchy skin, lips or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
- A rash that does not fade when you roll a glass over it, the same as meningitis
- Difficulty breathing (you may notice grunting noises or their stomach sucking under their ribcage), breathlessness or breathing very fast
- A weak, high-pitched cry that’s not like their normal cry
- Not responding like they normally do, or not interested in feeding or normal activities
- Being sleepier than normal or having difficulty waking
They may not have all these symptoms.
If you think you or someone else has symptoms of sepsis, call 999 or go to A&E.
Source: NHS
After Monday’s hearing, an ITH Pharma spokesperson said: “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 also heard from the family of Aviva Otte, whose death came before the infected batch of TPN was provided to St Thomas’ Hospital by ITH Pharma.
The inquest is due to last three weeks.
