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The inquests into two deaths following an outbreak of a waterborne pathogen at a world-leading cardiothoracic transplant centre.
The deaths, at the newly-opened Royal Papworth Hospital in Cambridge, followed infection by a form of bacteria – M.abscessus – previously unknown to have affected a UK hospital water system. The inquests heard that the bacteria are not usually harmful to humans, but can cause severe illness in some individuals, including those suffering from cystic fibrosis, the immunocompromised, and lung transplant patients. The relevant safety guidance, published by the Department for Health, failed to identify M.abscessus as a risk in healthcare settings.
The coroner, Keith Morton KC, recorded a narrative conclusion and directed a preventing future deaths report, concerning the published guidance, to the Secretary of State for Health and Social Care.
Charles Curtis represented the Royal Papworth Hospital NHS Foundation Trust. Dominic Adamson KC represented NPH Healthcare Ltd. Nicholas Chapman represented OCS Group UK Ltd.