Baby died of hospital infection despite ‘overcrowding’ warning

A baby died with an infection caught on a neonatal unit, despite earlier warnings about outbreaks due to its “approach to overcrowding” of cots, HSJ has learned.

The death happened at Leeds General Infirmary between December 2022 and March 2023, during an outbreak of the Serrratia healthcare-associated infection on the L43 unit.

An internal paper from March 2023 seen by HSJ refers to “the death of one neonate being directly attributed to an organism associated with cross-transmission within L43”. 

The paper also reveals that – following earlier outbreaks on the unit, including both Serrratia and Klebsiella in 2021 – experts from the UK Health Security Agency had predicted there would be more outbreaks, due to the unit’s “approach to overcrowding”.

Leeds Teaching Hospitals Trust had apparently tried to reduce the number of cots on the L43 unit in September 2022 from 34 to 22, with two additional “surge” cots.

But regional demand pressure meant it failed to keep numbers down, with an average of 26 cots occupied in December 2022 and numbers hitting 32 on some days, according to information seen by HSJ. The unit takes some of the sickest babies from across the region.

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Source: HSJ, 26 June 2025