Grandma, 81, died after eating NHS hospital sandwich contaminated with listeria

A grandma has died after eating a chicken mayonnaise sandwich contaminated with listeria while she was in hospital, an inquest found.

Brenda Elmer, 81, was presumed to have been recovering from an operation, but was in fact battling listeria picked up from a sandwich made by Good Food Chain company.

Brenda, from Gravesend, Kent, was one of nine patients who contracted listeria after eating NHS sandwiches or salads following a national outbreak from the sandwich provider which supplied 43 health trusts.

Following an operation on May 3 last year, Brenda was discharged from St Richard's Hospital, in Chichester, West Sussex, but was re-admitted a month later as she was "simply was not communicating".

She died on June 17. An inquest into her death was held at Centenary house in Crawley, West Sussex, today.

Her family were not aware of the listeria outbreak until they saw it on TV news while sitting in the hospital.

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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 which was linked to the food chain, causing it to fall into liquidation last year.

An information "black hole" also meant that warnings over the outbreak were delayed in reaching Brenda's family, senior coroner Penelope Schofield said.

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.

The pensioner, who had breast cancer, had been admitted for an unrelated operation and was discharged on May 3.

Her son, Jonathan, 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."

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He said his mother had felt weak as she recovered from her operation at home, 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 Brenda'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.

Coroner Mrs Schofield suggested that an information "black hole" for patients discharged to areas outside the hospital's trust area may have prevented Brenda'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."

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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 Brenda 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 Brenda'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.

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.

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