Transplant patients die after drinking infected water from hospital supply

The pair were being treated at the Royal Papworth Hospital’s new site in Cambridge. They caught Mycobacteria Abscessus from the trust’s infected water, a coroner has ruled.

In a prevention of future death report, assistant coroner for Cambridgeshire and Peterborough Keith Morton said neither would have died without catching M Abscessus.

Papworth’s new site alongside Addenbrooke’s hospital opened in May 2019. Karen Starling and Anne Martinez were among the first patients to receive lung transplants at the new hospital. Ms Starling died in February 2020, and Ms Martinez in December of the same year.

Mr Morton KC said in his report that the infection was: “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.”

The bacteria poses a threat to all immunocompromised people and the report said 34 patients at Royal Papworth had contracted M abscessus from the hospital’s water, with cases “continuing to be reported, albeit at a declining rate”.

Papworth is the biggest transplant unit in the country. It performed 19 lung transplants in 2020-21.

Chief executive Eilish Midlane said in a statement: “While the coroner acknowledged that we had followed national guidance in place at the time for the testing and management of water safety, we are grateful for the opportunity to review the findings in full so that any further learning is embedded and shared.

“We launched an investigation as soon as this issue was identified in 2019, and took immediate action to ensure patient safety, including installing specialist filters on taps and showers and enhanced treatment of the water supply, which regular testing shows has remained effective.”

The trust said it had installed “point of use” filters on water outlets and provided bottled water to some patients in November 2019 and had installed a hydrogen peroxide dosing plant and an ultra-violet treatment unit on-site the3 following month.

The coroner also found that the latest Department of Health and Social Care guidance on water safety, issued in 2016, carried no mention of M abscessus. It added the bacteria was commonly found in the water supply of new hospitals.

Mr Morton said the guidance needed “urgent review and amendment”, as it was the “key document” for hospital estate managers and water safety groups and “purports to provide comprehensive guidance”.

The DHSC was approached for comment.

The prevention of future deaths report was also sent to occupational health and medical services company NPH Healthcare Limited, builders Skanska Construction UK Limited and facilities management firm OCS Group UK Limited.

The DHSC has until January 2 to respond to the coroner’s office.