Brenda Elmer · Prevention of Future Deaths report

On 22nd January 2018 I commenced an investigation into the death of Brenda Elmer aged 81 years. The investigation concluded at the end of the inquest on 5th February 2020 The conclusion of the inquest was a Narrative Conclusion which was recorded as:-

Brenda Elmer died from complications associated with a Listeria infection that she had contracted from a contaminated sandwich provided by an external supplier whilst an inpatient at St Richard's Hospital, Chichester. This was part of a national outbreak.

At the conclusion of the Inquest indicated that I was minded to make a Regulation 28 report.

Regretably whilst the indication to make a Regulation 28 report was made at the Inquest the issue of the prevention of future death report has been delayed due to the additional workload that has ensured due to the current pandemic for which I apologise.

Mrs Elmer underwent an operation at St Richards Hospital on 1st May 2019 and was discharged on 3rd May 2019. In preparation for this operation she attended the Hospital on the 5th February, 25th April and 30th April. Unfortunately on one of these occasions she consumed a contaminated sandwich which led to her acquiring a Listeria infection. On 2nd June 2019 she became very unwell and was admitted to Tunbridge Wells Hospital, which was her local hospital. She was treated for this infection but despite active treatment, over a prolonging period, she sadly did not recover from this infection and she died on 17th July 2019.

First Concern

1. Mrs Elmer attended St Richards Hospital, Chichester, for elective surgery. She had attended the hospital for a Pre Operation Assessment on 25th April 2019 and was admitted for her surgery on 30th April 2019. Whilst attending the hospital she acquired a Listeria infection from a chicken sandwich although this was not know at the time. Mr Elmer did not live in Sussex and following her treatment she returned home to Kent on 3rd May 2019.
2. Western Sussex Hospital Trust, NHS England and Public Health England (PHE) first become aware of a possible outbreak on Listeria on 19th May 2019 when blood cultures from another patient at the Worthing Hospital site confirmed a listeria infection. On 26th May 2019 NHS England notified all hospitals of a national outbreak of Listeria and a possible link to sandwiches that has been provided by the Good Food Company, a supplier to a number of Trusts.
3. Whilst it was accepted that details of the possible outbreak were shared locally with other medical professionals (and therefore there was a local knowledge of the Listeria outbreak) there did not appear to be any attempt by NHS England or PHE (by way of a Public Health message) to communicate with those patients who were treated within the Trust but who were now out of the area in different parts of the Country.
4. It was unfortunately that when Mrs Elmer fell ill, neither her GP who initially treated her, nor her family had any idea that her illness may be connected to the Listeria outbreak. This meant that she was not prioritised for a blood test and this delayed her being treated appropriately for Listeriosis. This diagnosis was only made when she was admitted to Tunbridge Wells Hospital, her local hospital in Kent following an emergency admission. It is unknown whether earlier treatment would have changed the outcome but it may have eased Mrs Elmer’s suffering.
5. Consideration needs to be given to how communications should be disseminated following such an outbreak so that as many patients as possible, who had been in the hospital at the relevant time, are made aware and can seek medical assistance if they become unwell.

Second Concern.

1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time. If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.