Mr. Clinton Peter Fear · Prevention of Future Deaths report

On 26th July 2022 an investigation into the death of Mr. Clinton Peter Fear was commenced. The investigation concluded at the end of the inquest 29th June 2023. The conclusion of the inquest was -

Mr Fear died from a Mycobacterium Chimaera infection acquired from a Liva Nova heater cooler unit during open heart surgery.

The cause of death was –

1a) Hospital acquired pneumonia;
b) Disseminated Mycobacterium Chimaera infection following a composite aortic root replacement (November 2012).

Mr Fear underwent cardiac valve replacement surgery in November 2012 and during surgery he contracted Mycobacterium Chimaera infection from a Liva Nova heater cooler unit (part of the heart bypass machine).
He developed symptoms of Mycobacterium Chimaera in the form of night sweats in 2017/2018, was diagnosed and started on treatment in October 2019, suffered a protracted disabling illness for 3 years and died from the infection in July 2022.

He was not notified of the risk of Mycobacterium Chimaera infection from the operation when this risk became known in 2015 because his operation was before January 2013 – the date from which patients were then considered to be at risk and adopted in guidance from Public Health England.
Mr Fear contracted his Mycobacterium Chimaera infection at surgery before January 2013 and other cases have been reported from surgery dating back to at least 2008.

1. There is an inconsistency between –

Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection

And

Evidence of patients contracting Mycobacterium Chimaera infection from surgery substantially earlier than January 2013 (at least as far back as 2008);

2. There appears to be no current basis for maintaining a start date of surgery in January 2013 for patient risk notification when there is evidence of infection substantially earlier than this date;

3. Patients who have contracted Mycobacterium Chimaera infection from surgery before January 2013 may be suffering a delay in diagnosis and consequent harm as a result of a lack of notification due to the existing guidelines.