NHS fined £300,000 after chemo patient's death traced to contaminated water

The NHS has been fined £300,000 after the death of a chemotherapy patient was traced to contaminated water.

Gloucestershire Hospitals NHS Foundation Trust has been ordered to pay the sum after the patient contracted a fatal bacterial infection from a contaminated shower.

Dr Chris Elliot, 59, died in 2022 after being exposed to Pseudomonas bacteria while receiving treatment at Cheltenham General Hospital.

The infection was traced to a showerhead in his ward's ensuite bathroom.

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The trust, which operates both Cheltenham General and Gloucestershire Royal Hospital, pleaded guilty to causing avoidable harm at Cheltenham Magistrates' Court.

The prosecution was brought by the Care Quality Commission.

Water samples taken on August 1 2022, revealed that the showerhead tested positive for Pseudomonas aeruginosa.

Despite this result, no remedial measures were implemented and the bathroom continued to be used by patients.

Dr Elliot was admitted to the ward eight days later, on August 9, to undergo chemotherapy as part of his cancer treatment.

He subsequently developed an infection that genetic testing confirmed matched the bacteria found in the shower water.

His condition worsened despite medical intervention, and he died on August 23.

Medical evidence presented to the court indicated the infection was "highly likely" responsible for his death.

Victoria Elliot delivered an emotional statement to the court, describing her husband as a "sitting duck" and declaring that those responsible should "hang their heads in shame."

She told the court: "Chris was my rock. Colossal intellect.

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His death has negatively shaped our lives forever."

Mrs Elliot said her husband "was treated with arrogance and incompetence with regards to his safety" and that both the trust and its contractor had failed to protect him.

She described him as "a true gentleman" with "a brain the size of a planet" who was "driven by a belief in fairness."

His sister, Vicky Elliot-King, remembered him as someone with "boundless enthusiasm" who "had the ability to make everything okay."

The court heard that the trust had delegated water sampling responsibilities to NHS Gloucestershire Managed Services in 2021, but oversight of this arrangement proved inadequate.

A water safety group meant to convene quarterly had not met for nine months during 2021, and early concerns about competence were never pursued.

Prosecutor James Marsland told the court there was no evidence that GMS had taken appropriate action following the positive test result, nor had the findings been communicated to ward managers or infection prevention staff.

The contractor claimed to have replaced the showerhead and a filter, but could provide no documentation to support either assertion.

District Judge Nick Wattam ruled that the trust had failed in its duty as a healthcare provider, imposing a £300,000 fine, a £2,000 victim surcharge, and £22,143.47 in costs.

Trust chief executive Kevin McNamara said the organisation was "deeply sorry" for Dr Elliot's death, calling it "a tragedy that should never have happened."

He confirmed the trust had entered an early guilty plea and accepted full responsibility for the failures.

Catherine Campbell, the CQC's deputy director of hospitals in the South West, said: "Dr Elliot was at particular risk of infection when he was admitted to Cheltenham General Hospital because he was immunosuppressed.

"He had the right to expect that risks within the hospital were being effectively managed to keep him safe.

"Had Gloucestershire Hospitals NHS Foundation Trust ensured there were effective systems in place to manage water safety at the hospital, he would not have been placed in a room with a shower head that had tested positive for pseudomonas aeruginosa."

She described the trust's failure to protect him from avoidable harm as "unacceptable."

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