Lawyers Help Establish Answer For Families As Coroner Issues Prevention Of Future Deaths Report

The families of two women, who died after being diagnosed with a bacterial infection linked to a hospital outbreak, have spoken out following an inquest into their deaths. 

Karen Starling, aged 54, and Anne Martinez, aged 65, both tested positive for Mycobacterium Abscessus (M.abscessus) after successfully undergoing double lung transplants at the Royal Papworth Hospital in Cambridge. They were from Ipswich and Borehamwood respectively.

A NHS serious incident report found that 21 patients with lung conditions were infected with M.abscessus, in the months after the specialist heart and lung hospital opened in May 2019. The “most credible source” of the outbreak was the hospital’s water supply becoming contaminated, the report by Royal Papworth Hospital NHS Foundation Trust, which runs the site, found.

More than 30 patients believed to have been affected by bacterial infection outbreak 

However, during the inquest into Karen’s and Anne’s deaths, it was heard that the latest figures from the Trust showed that 34 patients are likely to have been infected in the outbreak, after testing positive for the bacteria, M.abscessus. 

The Trust said there was no evidence patients became infected because of any problems with the clinical care provided to patients, or the way facilities were managed at the hospital. 

During the inquest, evidence was given from those working at the Trust at the time the hospital opened, that there were concerns over whether flushing of water systems was being performed effectively after the hospital opened in May 2019, due to a lack of resource. Flushing is a necessary step to avoid stagnant water and the growth of bacteria in water systems.

Karen and Anne's families ask lawyers to help establish answers

Following the deaths of Karen and Anne, their families instructed expert public health lawyers at Irwin Mitchell to help investigate and support them through an inquest. The law firm also represents a number of surviving patients who were diagnosed with M.abscessus following surgery at the Royal Papworth. 

Loved ones want lessons to be learned 

Karen’s and Anne’s families have now joined their legal team at Irwin Mitchell in calling for lessons to be learned. It comes after a joint inquest into their deaths recorded a narrative conclusion. 

Keith Morton, assistant coroner for Cambridgeshire and Peterborough, found that Karen and Anne’s M.abscessus was a hospital acquired infection. It was likely both were exposed M.abscessus in the hospital water at some point during their stay at the Royal Papworth. 

Coroner to issue prevention of future deaths report

The coroner said he would issue a prevention of future deaths report in which he would write to the Department of Health and Social Care calling on it to outline what measures it will take to reduce similar deaths in the future. 

Mr Morton said he was concerned there was a “lack of understanding” as to how M.abscessus entered the hospital’s water system. He added there was “an absence” of guidance to hospitals in the Health Technical Memoranda – designed to advise on the design, installation and operation of specialist buildings and technology used in healthcare – relating to identifying and controlling M.abscessus. 

This gave risk to future deaths, especially in new hospitals and among patients with weakened immune systems, the coroner added.

Expert Opinion

“This outbreak has had a major impact on the lives of those we represent and their families, but none more so than on Karen and Anne, and their loved ones.

“Karen and Anne were hopeful that their transplants would greatly improve their quality of life. While the surgical care they received isn’t in question, the events that unfolded afterwards have had a devastating effect.

“While nothing can make up for their loss, we’re pleased that we’ve at least been able to secure the answers Karen and Anne’s families deserved.

“M.abscessus is an incredibly dangerous bacterial infection for lung transplant patients, who are particularly vulnerable.

“The Trust’s own investigation highlighted worrying areas and while we welcome the fact that it identified areas for future action, it’s particularly concerning that the latest update on the number of people who have been diagnosed with M.abscessus linked to the hospital, now stands at more than 30.

“Large public buildings with more complex water systems – such as hospitals, hotels and spas – can be at greater risk of water contamination. Following the inquest, it’s now vital that all lessons possible are learned, to reduce the risk of a similar outbreak happening again.

“We continue to support Karen’s and Anne’s families at this distressing time, as well as other patients affected by M.abscessus, who continue to be concerned by what happened to them.” Jennifer Hodgson

Mycobacterium Abscessus: Karen and Anne's stories

The inquest at Peterborough Town Hall was told that Karen, who suffered with chronic obstructive pulmonary disease, was told in May 2019 that she could undergo a transplant. 

After surgery there was a marked difference in the mum-of-six - which includes two stepchildren - and a grandmother-of-14’s condition, her family told the hearing. 

However, Karen was told on 9 October, 2019, that a sample taken from her lungs in the previous month had grown M.abscessus, but no treatment started then, the inquest was told. 

At the beginning of January 2020, Karen experienced a drop in lung function and throughout that month her symptoms got worse. It was explained to her that the most likely cause of her symptoms was the M.abscessus infection. Karen was admitted to the Royal Papworth towards the end of January 2020 and received intravenous antibiotics. She developed pancreatitis and died the following month. 

Primary school teacher, Anne, had lung disease and underwent a double transplant at the Royal Papworth in July 2019. Shortly afterwards, a sample taken from Anne’s lungs on 25, July 2019, confirmed that she had been infected with M.abscessus. 

Initially her condition was monitored, but by October 2019 Anne began experiencing shortness of breath and there was a dramatic decline in her lung function. Treatment for M.abscessus later began on 18 October, 2019. By the end of October, Anne was advised that the infection had travelled to her blood.

The following month, it was noted that the antibiotics used to treat the infection had impacted Anne’s health and there were signs of acute kidney injury. Her health continued to deteriorate, and Anne was advised that the most likely cause was the antibiotic regime to treat the infection.

The inquest was told that treating doctors concluded in April 2020 that her best hope was for treatment with the antibiotic bedaquiline. However, its use was initially not sanctioned. 

Anne received a one month trial of the drug in September 2020. She died in December 2020. During the inquest, it was heard that Anne’s respiratory transplant consultant would like to see bedaquiline, on the list of approved drugs to treat this condition.

Karen Starling family tribute

In a statement, Karen’s husband Derek said after the inquest: “Karen was such a loving and caring person. She was the best mum and grandma anyone could wish for. To her our family was everything. 

“In the weeks after her transplant we saw a marked difference in her. It felt like she had a new lease of life. She had stopped using the stairlift and was able to walk round the shops once more. However, once we were told about her infection, everything seemed to change. 

“To see her so unwell was absolutely heart-breaking. We were all praying she would pull through but she couldn’t because of her weakened immune system. 

“Losing Karen in the way we did is something my family will never get over. She’s left a huge void in all our lives. 

“While the last three years has been awful for us we take some small comfort from at least having answers. “We now just hope that lessons can be learned to protect others.” 

Anne Martinez's sons hope others don't have to go through what they have 

In a joint statement, Anne’s sons Anthony, 40, and Andrew 35, said: “Mum was everything to us. She was kind, compassionate and always wanted the best for not only us, but other children through her work as a teacher. 

“The last couple of years and trying to come to terms with what happened have been the most difficult of our lives. If it wasn’t for the daily reminders of the loss we’ve suffered, it almost wouldn’t seem real. 

“When we received the news Mum was going to receive her transplant, as a family, we were overjoyed. Never did we envisage that things would turn out the way they did. 

“We still find it hard to understand why she was turned down for bedaquiline despite her treating doctors recommending it. We’ll never know for certain but it’s difficult not to think whether things could have been different if she had received the treatment earlier. 

“We will never get over losing Mum and particularly in the way we did. We would do anything to have her in our lives, but we know that’s not possible. All we can hope for now is that others don’t have to go through the hurt and pain we continue to live with.”