Karen Lesley Starling and Anne Edith Martinez · Prevention of Future Deaths report

On 28 February 2020 I commenced an investigation into the death of Karen Lesley Starling, who died on 7 February 2020 aged 54. The investigation concluded at the end of the inquest on 11 November 2022.

On 31 December 2020 I commenced an investigation into the death of Anne Edith Martinez, who died on 17 December 2020 aged 65. The investigation concluded at the end of the inquest on 11 November 2022.

Both deceased underwent successful lung transplant procedures at the new Royal Papworth Hospital. Both deceased subsequently contracted a hospital acquired infection, namely Mycobacteria Abscessus (M abscessus) in consequence of which they died. My Narrative Conclusion is summarised, so far as relevant to this report, in the circumstances of the deaths below.

1. These inquests were heard concurrently because there was an issue common to both, namely the presence of M abscessus in the water at the Royal Papworth Hospital (“the hospital”), which caused both deceased to become infected with M abscessus.

2. The hospital opened to patients on 1 May 2019. Mrs Starling and Mrs Martinez underwent lung transplant procedures on 25 May 2019 and 5 July 2019 respectively. They were among the first patients to be treated at the new hospital.

3. Neither Mrs Starling nor Mrs Martinez would have died at the time or in the circumstances they did but for their exposure to M abscessus while patients at the hospital.

4. M abscessus is an environmental non-tuberculous mycobacterium (NTM). It can sometimes be found in soil, dust and water, including municipal water supplies. It is usually harmless for healthy people but may cause opportunistic infection in vulnerable individuals. Lung transplant patients and lung defence patients such as Mrs Starling and Mrs Martinez were at particular risk of infection from mycobacteria, including M abscessus.

5. The guidance available to those responsible for the design, construction and operation of hospitals, including hospital water systems was Health Technical Memorandum (“HTM”) 04-01 published by the Department of Health. That guidance was directed at the identification and control of legionella and pseudomonas. It gave no relevant guidance in relation to mycobacteria and none in relation to M abscessus. HTM 04-01 did not require routine testing for mycobacteria, including M abscessus, or provide guidance on acceptable levels (if any) in the water systems. Therefore, compliance with the guidance does not identify or guard against the risk from M abscessus.

1. It is recognised that M abscessus poses a risk of death to those who are immunosuppressed. That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients. To date, 34 patients at Royal Papworth have contracted M abscessus from the hospital’s water. Cases continue to be reported, albeit at a declining rate;

2. There is an incomplete understanding of how M abscessus may enter and/or colonise a hospital water system;

3. Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because:

a. It is a key document for hospital estate managers and Water Safety Groups;

b. It purports to provide comprehensive guidance on waterborne bacteria;

c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M abscessus. It provides no guidance on the identification and control of M abscessus. It does not require routine testing for mycobacteria, including M abscessus or provide guidance on acceptable levels (if any). Compliance with the guidance does not identify or guard against the risk from M abscessus;

d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed;

e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety.

4. There is evidence that the risk from M abscessus is especially acute for new hospitals. Consideration needs to be given to whether special or additional measures are required in respect of the design, installation, commissioning and operation of hospital water system in new hospitals.