Food safety lessons to be learned from fatal listeria outbreak

A sandwich supplied by The Good Food Chain to 43 NHS Trusts across England, Wales and Scotland led to an outbreak of listeria which resulted in six deaths in 2019.

The public health incident was followed by the usual investigations to find out what went wrong, and what needed to change to prevent a similar outbreak.

Does more need to be done to keep the public safe from such a risk?

Listeria is a bacterium which can cause a type of food poisoning called listeriosis and can be found in many types of food such as soft cheeses, chilled ready-to-eat foods like pre-packed salads, sandwiches and sliced meats, and unpasteurised milk products.

Brenda Elmer, aged 81, underwent an elective operation at St Richard’s Hospital in Chichester, West Sussex (Western Sussex Hospitals NHS Foundation Trust) on 1 May 2019 and was discharged on 3 May 2019.

While attending one of her pre-operative appointments in February and April 2019 Mrs Elmer ate a chicken sandwich produced and supplied by The Good Food Chain. The contaminated sandwich caused Mrs Elmer’s listeria infection and on 2 June 2019, Mrs Elmer’s health deteriorated, and she died on 17 July 2019.

Three cases of listeriosis were also identified at Manchester University NHS Foundation Trust and Aintree University Hospital NHS Foundation Trust in Liverpool.

Subsequent investigations into food histories and the supply chain at both hospital trusts concluded that everyone who had contracted listeria had one thing in common – they all had consumed a chicken mayonnaise sandwich supplied by The Good Food Chain.

Further investigations indicated that The Good Food Chain had supplied sandwiches to 43 NHS Trusts across England, Wales, and Scotland. On 25 May 2019, The Good Food Chain voluntarily withdrew products containing chicken from hospitals and the Incident Management Team advised the 43 NHS Trusts affected against serving all sandwiches supplied by The Good Food chain.

Details of a possible outbreak were shared locally with other medical professionals, but not with Mrs Elmer, who did not live in Sussex (where the operation took place). According to Senior Coroner Penelope Schofield: “It would appear that there was no attempt by NHS England or PHE to inform those patients who were treated within the 43 Trusts but were now out of the area in different parts of the county of the possible outbreak.”

As of February 2020, six people died from listeria after eating chicken sandwiches supplied to hospitals by the Good Food Chain. Meat was produced by North Country Cooked Meats and distributed by North Country Quality Foods. All three firms went into liquidation and ceased trading.

At an inquest into Mrs Elmer’s death which concluded on 5 February 2020 a number of concerns were raised and highlighted that further deaths will occur unless action is taken. A Regulation 28 report was made on 14 August 2020 and sent to NHS England and Public Health England (PHE).

According to a representative of Public Health England who gave evidence at the inquest there is no legal requirement for Private Laboratories who identify Listeria in food to share the isolated listeria sample with PHE or indeed keep the sample for any period of time. Nor is there any legal requirement for hospital trusts to send in isolated listeria samples when Listeria has been identified, which in turn does not allow PHE to match particular strains and identify outbreaks which may be connected.

PHE’s response to the report on 28 October 2020 did highlight that communication to the public needs to be greatly improved. They also held the usual “lessons will be learnt” exercise across multiple agencies which also highlighted a need to review hospital food polices.

Their response included the standard ‘they are mandated to investigate but have no legislative powers to implement action on the NHS or to implement food safety measures’. NHS England’s response to the Regulation 28 report is yet to be published.

To prevent future deaths several changes, need to be made. Namely, a joint effort by Private Laboratories, PHE and Hospital Trusts when there is a suspected outbreak of a disease to trace the source of infection, withdrawal of the contaminated product and notification to all potential victims whether they are local or not. Otherwise, sadly there will be many more victims of Listeria.

Whilst it is important to note is that whilst the Food Safety Agency confirmed that The Good Food Chain was not the source of the outbreak, they supplied the sandwich to the Hospital Trusts and therefore had a certain degree of responsibility to ensure that their products were fit for consumption.