E. coli deaths 'caused by infection prevention failure'
A failure in preventing infections was the most likely cause of an E. coli outbreak at a hospital where two premature babies died after contracting the bug, a health watchdog has found.
The outbreak at Swansea's Singleton Hospital involved a mother, her twins and a third baby in November 2011.
All three babies and the twins' mother were found to have the same EBSL strain of E. coli.
The neo-natal unit was shut for about a month following the outbreak.
A report by the Health Inspectorate Wales (HIW) said during the lead up to the outbreak, the unit was busy and operating beyond the contracted cot allocation.
What is ESBL E. coli?
- ESBL E. coli is not the same as the E. coli O157 which causes food poisoning
- ESBL stands for Extended Spectrum Beta Lactamase
- ESBL E. coli is most often found in the gastrointestinal tract but may cause urinary tract infections
- ESBL E. coli is resistant to commonly-used antibiotics such as penicillin, but can be treated
- In most people ESBL E. coli does not cause harm but in vulnerable individuals it can cause serious infections
Source: ABM health board
All three babies were premature and were delivered by caesarean section on 31 October, needing neo-natal intensive care at birth.
After giving birth, the twins' mother showed signs of E. coli infection with one twin developing it and other serious medical complications later before dying on 8 November.
The third baby, who was being cared for in an incubator cot next to one of the other babies also acquired E. coli and died on 4 November.
The HIW said this was a significant factor in what happened.
The other twin also had the infection, but survived and was allowed to go home on 17 November.
Tests at the time by Abertawe Bro Morgannwg University Health Board (ABM) showed one of the babies who died contracted E. coli at the unit, but the mother and other two babies caught it elsewhere.
"While the exact cause of the transmission event and hence the outbreak cannot be determined it was most likely caused by a failure in infection prevention control within the neo-natal unit (NNU)," said HIW in its report.
"However, as a consequence of the actions taken by staff on the NNU, the infection prevention control team, the outbreak management team and ABM, the outbreak was limited to just the one transmission event."
HIW has given 13 recommendations for improvements.
Internal reviews by ABM also identified areas of improvements, including hand washing and the need to increase the spacing between neonatal cots in the unit.
ABM said a £3.2 million refurbishment of the neonatal unit since included the creation of a special isolation room to greatly reduce the risk of cross infection.
A spokesperson from ABM said: "Infection control audits also show a consistently excellent rate of compliance at the unit, and staff are committed to providing excellent, safe care for the babies in their care."