Hospital water supply faces bacteria risk - coroner

Anne Martinez (left) and Karen Starling died the year after undergoing double lung transplants

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, 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.

The new Royal Papworth Hospital opened in Cambridge in 2019 after moving from nearby Papworth Everard

Mrs Starling, from Ipswich, suffered with chronic obstructive pulmonary disease and was recommended for a lung transplant in 2014, undergoing the procedure in 2019.

However, by the September she began to develop shortness of breath. In January 2020 she was readmitted to Royal Papworth, but her health deteriorated and she died a month later.

Mrs Martinez, of Borehamwood in Hertfordshire, received a lung transplant at the hospital in July 2019 and shortly afterwards contracted mycobacterium abscessus.

At their inquests the hospital trust said it had followed national guidance in place at the time, and when the issue was identified in 2019 it "took immediate action to ensure patient safety".

The Health Secretary Steve Barclay, who is the Conservative MP for North East Cambridgeshire, and the Department of Health and Social Care have 56 days to respond with a timetable of action they propose to take, or explain why no action is proposed.