Karen Lesley Starling died on 7 February 2020 aged 54 and Anne Edith Martinez died on 17 December 2020 aged 65. Both deceased underwent successful lung transplant procedures at the new Royal Papworth Hospital. However, both women became infected with a hospital acquired infection, namely Mycobacteria abscessus (M. abscessus), and died.
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.
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.
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