NHS fined after death traced to contaminated water

An NHS hospital trust has been fined more than £300,000 after a chemotherapy patient who showered in contaminated water later died.

Dr Chris Elliot, 59, died in 2022 after being infected by a strain of pseudomonas bacteria from contaminated water from a shower head while being treated at Cheltenham General Hospital.

Gloucestershire Hospitals NHS Foundation Trust, which runs the hospital, admitted causing avoidable harm at Cheltenham Magistrates' Court earlier.

Chris' wife Victoria Elliot told the court he was a "sitting duck" and those responsible should "hang their heads in shame".

The trust runs Gloucestershire Royal Hospital and Cheltenham General Hospital, the two largest hospitals in the county.

The case against the trust was brought by health watchdog the Care Quality Commission (CQC).

James Marsland, prosecuting, told the court the trust delegated water sampling and testing to NHS Gloucestershire Managed Services (GMS) in 2021.

He said oversight of GMS was "insufficient", as a water safety group which was supposed to meet quarterly had failed to meet for nine months in 2021.

He added "initial concerns over competence" were not followed up.

The court heard Elliot was admitted for chemotherapy on 9 August 2022 as part of his cancer treatment.

He then developed an infection, which genetically matched the sample from the water of a shower head in the ensuite bathroom of his ward.

On 1 August, water sample tests confirmed the same shower head had tested positive for pseudomonas aeruginosa, the bacteria which developed into Elliot's infection.

No action had been taken had been taken and the ensuite bathroom remained in use.

Marsland said there was no evidence GMS took sufficient action, adding it was not reported to the ward manager or the infection prevention team.

As a result, the room remained in use.

Marsland said there was no evidence GMS changed the shower head despite the service claiming it did.

According to Marsland, GMS claimed it had changed a filter but offered no evidence it happened.

Despite treatment, Elliot's condition deteriorated and he died on 23 August 2022.

The court heard medical evidence suggested it was "highly likely" the infection was the cause of death.

It also heard retest samples were taken after his death and, on 26 August 2022, contamination was still found.

Victoria Elliot told the court: "[He] was treated with arrogance and incompetence with regards to his safety. GMS and the trust failed to safeguard him.

"Chris was my rock. Colossal intellect. His death has negatively shaped our lives forever.

"He had many passions in life. In hospital he was intent on being productive.

"He was a true gentleman. [He had a] brain the size of a planet. He was driven by a belief in fairness."

Chris Elliot' sister, Vicky Elliot-King, told the court he "had the ability to make everything okay" and had "boundless enthusiasm".

Sentencing the trust, District Judge Nick Wattam said it failed in its duty as a health service provider, adding the failure caused avoidable harm.

He fined the trust £300,000 and ordered it to pay a £2,000 victim surcharge and £22,143.47 costs.

The judge said the maximum sentence is a fine and it is not a measure in any way of his life or of his death.

In mitigating factors, the judge said the trust had no previous convictions, and clearly stated remorse while co-operating.

In a statement after the meeting, the trust's chief executive Kevin McNamara said it was "deeply sorry" for Elliot's death, adding it was a "tragedy that should never have happened".

He said: "The trust entered an early guilty plea and accepted full responsibility for the failings identified, which meant water test results were not shared by our contractor in a timely manner.

"This would have allowed swift action to be taken by the trust to restrict access to the room where care was being provided.

"We co-operated fully with the CQC throughout its investigation.

"We had already conducted our own detailed investigation following the incident and shared the findings with the family, regulators and partners."

Speaking after the hearing, the CQC's deputy director of hospitals in the South West Catherine Campbell 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 added the trust's failure to protect Elliot from avoidable harm was "unacceptable".

Follow BBC Gloucestershire on Facebook, X and Instagram. Send your story ideas to us on email or via WhatsApp on 0800 313 4630.