Grandmother died after eating listeria-contaminated sandwich at West Sussex hospital, inquest hears
A happy and active grandmother died weeks after eating a chicken mayonnaise sandwich contaminated with listeria at St Richard’s hospital in West Sussex, an inquest has concluded.
For several days, Brenda Elmer’s family thought the 81-year-old was simply recovering from a recent operation, rather than battling the potentially life-threatening bacteria.
A coroner branded delays in reporting some listeria cases as “inexcusable” and said it hindered the national response to last year’s outbreak of the infection.
An information “black hole” also meant that warnings over the outbreak were delayed in reaching Mrs Elmer’s family, senior coroner Penelope Schofield said.
Mrs Elmer is one of five people thought to have died in last year’s national listeria scandal, linked to sandwiches that had been supplied to 43 NHS trusts.
It prompted a “root and branch” review of hospital food in the UK by Public Health England.
Listeria monocytogenes causes an illness called listeriosis which can incubate for up to 70 days and can be fatal for people with weakened immune systems.
Mrs Elmer died on July 17 2019 and an inquest was taking place at Centenary House in Crawley, West Sussex, on Wednesday.
The pensioner, who had breast cancer, had been admitted to St Richard’s Hospital in Chichester, West Sussex, for an unrelated operation and was discharged on May 3.
During her hospital stay it is thought that she ate a chicken sandwich made by The Good Food Chain company, unaware that it was contaminated with listeria.
Her son, Jonathan Elmer, told the inquest: “She was a family lady first and foremost. She tied us together, a great mum, great wife.
“She lived life to the full: enjoyed travel, enjoyed family, enjoyed people.”
He said his mother had felt weak as she recovered from her operation at home in Gravesend, Kent, but they had no idea at the time that it could have been listeria.
He said: “It is certainly something that goes through your mind.
“To this day I do not know if an earlier diagnosis may have been of any benefit.”
A blood test from Mrs Elmer’s GP took several days to come back and the results were inconclusive.
However the pensioner was rushed to hospital in Tunbridge Wells on June 2 after becoming uncommunicative.
There she tested positive for listeria and died on July 17.
Coroner Mrs Schofield suggested that an information “black hole” for patients discharged to areas outside the hospital’s trust area may have prevented Mrs Elmer’s family from getting her early treatment for listeria.
Her widower, Alec Elmer, said: “I think, had we known earlier, something would have been done.
“Had we been aware earlier, that blood test would have been an emergency blood test. As it was, it took three or four days to get the results through.”
Dr Timothy Taylor, medical director for Western Sussex Hospitals NHS Foundation Trust - which runs Worthing Hospital and St Richard’s Hospital in Chichester - said there was “no mechanism” for getting hold of discharged patients who have eaten specific foods.
He told the inquest: “We had one previous case during May with a patient at Worthing Hospital but it wasn’t apparent at the time she had contracted listeria, it was part of the national outbreak that was emerging.”
But when information coming in suggested there was a “substantial” risk that Mrs Elmer had eaten a contaminated sandwich, he contacted his counterpart at her local hospital in Kent.
Dr Taylor added: “There has been a lot that we have learned from it but also a lot of reassurance that the procedures we have in place are robust.”
He said the news of Mrs Elmer’s death came as a shock to staff at St Richard’s and offered his condolences to her family.
Nick Phin, deputy director for the national infection service at Public Health England, said an investigation traced the listeria outbreak to sandwiches from The Good Food Chain, which used meat from North Country Quality Foods.
The two companies have since fallen into liquidation.
Giving her conclusion, Mrs Schofield said: “Brenda Elmer died from complications associated with a listeria infection that she had contracted from a contaminated sandwich provided by an external supplier whilst an inpatient at St Richard’s Hospital, Chichester.
“This was part of a national outbreak.”
The coroner said she was issuing two Prevention of Future Deaths reports - one to Public Health England about communication issues, and the other on the issue of wider reporting of listeria cases.
She said it was “inexcusable” that some cases of listeria had not been reported to PHE quickly enough - though notably not Western Sussex Hospitals NHS Foundation Trust, whose response, she said, was swift.
This, the inquest heard, delayed the national response to the crisis.
Following the inquest, Dr Taylor said: “We are pleased the coroner recognised the swift action we undertook to protect public health once we were made aware of the risk, and there was no criticism of the trust’s actions and its food handling procedures.
“We hope the inquest has given Mrs Elmer’s family a fuller understanding of the sad circumstances surrounding her death. Our thoughts are with them at this difficult time.”