A coroner has written to the health secretary warning a lack of guidance around a bacteria that could contaminate new hospitals' water supply may lead to future deaths.
It follows inquests into the deaths of Anne Martinez, 65, and Karen Starling, 54, who died a year after undergoing double lung transplants at the Royal Papworth Hospital in Cambridge in 2019.
Both were exposed to Mycobacterium abscessus, likely to have come from the site's water supply.
The coroner said there was evidence the risks of similar contamination was "especially acute for new hospitals".
In a prevention of future deaths report, external, Keith Morton KC, assistant coroner for Cambridgeshire and Peterborough, said 34 people had contracted the bacteria at the hospital since it opened at its new site in 2019.
He said the bacteria "poses a risk of death to those who are immuno-suppressed" and there was a "lack of understanding" about how it entered the water system.
There was "no guidance on the identification and control" of mycobacterium abscesses, the coroner said.
Mr Morton said documentation on safe water in hospitals needed "urgent review and amendment".
"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 systems in new hospitals," he said.
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Source: BBC News, 22 November 2022