Listeria in pre-packed chicken mayonnaise sandwiches was a ‘more than minimal’ cause of the deaths of two hospital patients during a deadly 2019 outbreak, an inquest jury concluded today.

Retired nurse Beverley Sowah, 57, and mother-of-five Enid Heap, 84, were given the sandwiches on successive days while patients at Manchester Royal Infirmary.

The women, who both had underlying health problems, died within days, prompting a national alert which saw the bacteria traced to a sandwich firm that supplied more than 40 NHS trusts.

A total of nine people were infected across England during the outbreak, of whom seven died, prompting then health secretary Matt Hancock to promise a ‘root and branch’ review of how food was served in NHS hospitals.

Retired nurse Beverley Sowah, 57, pictured, died after eating a chicken sandwich while undergoing treatment at Manchester Royal Infirmary

Retired nurse Beverley Sowah, 57, pictured, died after eating a chicken sandwich while undergoing treatment at Manchester Royal Infirmary

Mother-of-five Enid Heap, 84, also received chicken sandwiches over successive days which contained listeria

Mother-of-five Enid Heap, 84, also received chicken sandwiches over successive days which contained listeria

Today an inquest jury concluded that both Mrs Sowah and Mrs Heap died after developing listeriosis contracted from eating contaminated sandwiches.

In both cases, jurors concluded that listeria was a ‘more than minimal’ cause of their deaths.

They also concluded that the listeria entered the food chain at Salford-based North Country Quality Foods which sold the cooked chicken to sandwich manufacturer Good Food Chain.

From there, the contaminated meat was supplied to the hospital in the form of chicken mayonnaise sandwiches and served to both women, jurors said said.

The scandal over potentially deadly listeria in pre-packed hospital sandwiches in 2019 saw nine patients infected, with seven dying.

This week’s inquest into the first two victims, Beverley Sowah, 57, and mother-of-five Enid Heap, 84, saw details of how the bacteria entered the food chain spelt out for the first time.

It revealed how it was traced back to a chilled meat supplier based in Salford, Greater Manchester – probably through cross-contamination when the chicken was diced.

But experts were unable to pinpoint hygiene failings either at the producer, North Country Quality Foods (NCQF), or the sandwich firm the chicken was supplied to, Staffordshire-based Good Food Chain (GFC).

Sodexo, the catering contractor at Manchester Royal Infirmary – where both women were being treated – was also found to kept sandwiches at safe, chilled temperatures.

Both women were patients at Manchester Royal Infirmary when they ate infected sandwiches

Both women were patients at Manchester Royal Infirmary when they ate infected sandwiches

The 2019 outbreak sparked a public outcry, with the Mail revealing that food safety experts had warned three years earlier that hospitals were risking patients’ lives by serving them pre-packed sandwiches.

A 2016 report said that the packaged snacks had been responsible for ‘almost all’ hospital outbreaks of listeria over the preceding 13 years.

Questions were also asked over why Public Health England waited until June 7, 2019 to go public about the outbreak, by which point three patients had died.

That was nearly two weeks after the NHS was ordered to stop serving sandwiches and salads made by GFC.

In response, then Health Secretary Matt Hancock told the House of Commons he had ordered a ‘root and branch’ review of food served within NHS hospitals.

He pledged to MPs that a ‘full and thorough investigation’ would be held with ‘severe consequences if there’s any evidence of wrongdoing’.

This week’s inquest heard that while the source of the outbreak had been traced back to NCQF, inspections of its plant and the GFC sandwich factory found no evidence of poor hygiene.

However a report released by Public Health England at the height of Covid the following year – and hence largely ignored at the time – pinpointed shocking failings by hospitals, with fridges in many cases not cold enough to stop listeria multiplying.

Jamaica-born retired nurse Beverley Sowah, 57, was receiving palliative care for terminal cancer

Jamaica-born retired nurse Beverley Sowah, 57, was receiving palliative care for terminal cancer

A major report on food in the NHS – commissioned to fulfil Mr Hancock’s promise of a ‘root and branch’ review, and led by Bake Off judge Prue Leith – was published in October 2020.

Among a string of recommendations highlighting how serving good quality food can boost hospital patients’ recovery, it said all NHS trusts should have someone at board level responsible for food safety lead to ensure hygiene standards.

Hospitals should also be registered with their local council as food businesses to ensure regular inspections, it said.

However food safety experts yesterday warned there was a risk of further listeria outbreaks if hospitals only ‘pay lip service’ to the recommendations.

Listeriosis is a rare but deadly infection caused by eating food contaminated with a bacteria called listeria monocytogenes. There are about 170 cases of listeriosis in the UK every year, and it kills about one in four of those affected, sometimes leading to sepsis or meningitis.

Most people who eat food contaminated with listeria develop mild flu-like symptoms that pass within a few days.

But listeriosis frequently proves deadly for those with weak immune systems – with pregnant women, newborn babies, people aged over 60 and those being treated by chemotherapy most at risk.

Listeria is most commonly spread in pre-packaged sandwiches and other chilled food, and is widespread in the environment, including in food production businesses.

Unlike many other bacteria, listeria thrives and reproduces at temperatures as low as 0°C. This enables it to survive in the fridge and pass through food-processing equipment and the food chain.

However storing foods below 5C and discarding uneaten produce before its use-by date – three days in the case of pre-packed sandwiches – should prevent listeria reaching harmful levels.

There has never been a major outbreak of listeriosis in the UK, but there have been product recalls following scares.

Jamaica-born retired nurse Beverley Sowah, 57, was receiving palliative care for terminal cancer.

She was admitted to Manchester Royal Infirmary on April 15, 2019 over fears the disease had spread to her spine.

Mrs Sowah was given a chicken mayonnaise sandwich on April 17 but later developed sepsis.

On April 26, tests revealed she was suffering from listeria infection, and she died later that day.

What is Listeriosis and why is it so dangerous?

Listeriosis is a rare but deadly infection caused by eating food contaminated with a bacteria called listeria monocytogenes. There are about 170 cases of listeriosis in the UK every year, and it kills about one in four of those affected, sometimes leading to sepsis or meningitis.

Most people who eat food contaminated with listeria develop mild flu-like symptoms that pass within a few days.

But listeriosis frequently proves deadly for those with weak immune systems – with pregnant women, newborn babies, people aged over 60 and those being treated by chemotherapy most at risk.

Listeria is most commonly spread in pre-packaged sandwiches and other chilled food, and is widespread in the environment, including in food production businesses.

Unlike many other bacteria, listeria thrives and reproduces at temperatures as low as 0°C. This enables it to survive in the fridge and pass through food-processing equipment and the food chain.

However storing foods below 5C and discarding uneaten produce before its use-by date – three days in the case of pre-packed sandwiches – should prevent listeria reaching harmful levels.

There has never been a major outbreak of listeriosis in the UK, but there have been product recalls following scares.

Retired pharmacy assistant, Enid Heap, 84, had been suffering from lung disease when she was admitted onto a different ward at the hospital on March 25, 2019.

On April 18 the mother-of-five was served with a chicken mayonnaise sandwich, but a listeria infection was not detected until May 3 and she died three days later.

With two cases in the space of a week, an ‘outbreak meeting’ was held the day after her death.

However it was not until May 16 that lab results established that both Mrs Sowah and Mrs Heap had been infected by identical strains of listeria, showing they had caught it from eating the same batch of food.

That was a day after haulage contractor Ian Hitchcock, 52, was admitted to Royal Derby Hospital with advanced cancer.

Examination of what the two women had eaten during their hospital stays narrowed the source down to sandwiches made by Staffordshire-based Good Food Chain.

It supplied 43 NHS trusts, all of which were told to stop serving its products to patients on May 24.

By now, 81-year-old Brenda Elmer had been discharged home after a stay at St Richard’s Hospital, Chichester, during which she too had eaten a contaminated chicken mayonnaise sandwich.

Mr Hitchcock died on June 8 – the day after Public Health England went public about the outbreak.

Last year an inquest jury concluded he had died from liver failure due to metastatic cancer and listeria infection.

They said it was ‘probable’ that he contracted listeria eating food on a hospital visit.

Jurors also said some fridges at Royal Derby Hospital were at ‘too high a temperature’, meaning sandwiches were ‘insufficiently chilled’.

In response, the trust said it had taken ‘immediate steps to improve aspects of how food was stored’.

Meanwhile Mrs Elmer, a ‘much-loved grandmother’ who was being treated for breast cancer, was struggling to recover at home in Gravesend, Kent following an unrelated operation.

She was rushed to her local hospital in Tunbridge Wells on June 2 after becoming uncommunicative, testing positive for listeria and dying on July 17.

A coroner, Penelope Schofield, later suggested that an information ‘black hole’ may have prevented Mrs Elmer being diagnosed sooner as she had not lived within the area of the trust where she ate the contaminated sandwich.

She said it was ‘inexcusable’ that some hospitals had not reported cases of listeria quickly enough

None of the three other patients whose deaths were linked to the outbreak were ever publicly named.

This week’s hearing heard how Public Health England was notified on May 7, 2019, the day after Mrs Heap’s death – the second case of fatal listeria infection at Manchester Royal Infirmary in ten days.

Listeriosis is especially dangerous for people who are immunocompromised or have an underlying illness

Listeriosis is especially dangerous for people who are immunocompromised or have an underlying illness 

The ‘primary hypothesis’ was that pre-packed sandwiches were to blame, but it was not until May 16 that lab results established both women had become infected by the same source.

By now, cases of listeria had been identified at other hospitals, and a national investigation was launched, the inquest jury at Manchester Coroner’s Court heard.

On May 24, sandwich supplier Good Food Chain was pinpointed as the source, and its products withdrawn, with the outbreak later traced back to its chicken supplier, North Country Quality Foods.

Giving evidence, NCQF managing director Jeffrey Thomas said cooked meat was kept below 5C throughout the process of storing, dicing, packaging and delivery.

Tests carried out by environmental health officers at both plants found evidence of listeria, the inquest heard – but none matching the strain which had infected Mrs Sowah and Mrs Heap.

However an unopened pack of diced chicken sent from NCQF to GFC tested on May 24 was found to contain listeria matching the outbreak strain at a level of 1,000 units per gram – ten times the legally permissible limit.

The inquest heard this was an ‘unprecedented level’ and the maximum that the testing lab could record.

Additionally, a pack of bacon sent by NCQF to a different supplier tested positive for the same outbreak strain of listeria.

With the contaminated sandwiches long since eaten or discarded, this was the only evidence definitively linking NCQF to the fatal outbreak.

Mr Thomas agreed the presence of the strain in two different meats supplied by his company – which is no longer trading – meant there must had been ‘cross-contamination at the dicing stage’.

But he insisted the bacteria would not have reached harmful levels as long as refrigeration and use-by rules were followed properly.

The inquest heard that the pack containing 1,000 units of listeria per gram had been delivered four days earlier, making it impossible to say whether it had been at an unsafe level when it was dispatched.

Environmental health officer Emma Norman was asked by Mrs Heap’s son Alistair whether the discovery of listeria at NCQF indicated ‘failures’ in cleanliness.

She replied: ‘No, it’s that the bacteria is very hard to get rid of when it’s established in a business.’

NCQF labelled its cooked chicken with a ‘use-by’ date of two days after opening, but GFC extended this to three days to give hospitals time to serve the finished sandwiches.

However David Bell, business development manager at GFC – also no longer trading – insisted sandwiches had remained safe to eat if properly stored once delivered to hospitals.

The inquest heard that the batches of sandwiches eaten by Mrs Heap and Mrs Sowah were checked on arrival by hospital catering contractors Sodexo and found to be under 5C.

Tina Potter, head of incidents at the Food Standards Agency, told the hearing the source of the listeria contamination had been traced to cooked chicken in the sandwiches the two women ate.

She said finding ‘genetically related’ infection ‘in two food products within the same business would lead us to a likely hypothesis that there’s an environmental contamination that’s persisted’.

But she said it was not possible to definitively confirm at what point between manufacture to consumption the outbreak strain was present at a level that meant it could be injurious to health.

As a result, coroner Zak Golombeck told jurors there was an ‘insufficiency of evidence’ for them to make a finding that breaches in the food supply chain contributed to Mrs Sowah and Mrs Heap becoming infected.

Afterwards Mrs Heap’s son Alistair said the two women’s deaths should serve as a reminder to the food industry of the potentially fatal consequences of failing to maintain high safety standards.

He said the case had ‘highlighted the importance that businesses involved in the food process should maintain a strict standard of care and be subject to rigorous testing when supplying food to the public, particularly vulnerable groups in hospital environments’.

Mr Heap said the five years since learning that listeria had contributed to their mother’s death had been ‘distressing and emotional’.

But he welcomed the ‘comprehensive understanding’ of the circumstances leading up to the tragedy which the inquest had provided.

Mrs Sowah’s eldest son Stephen said: ‘The conclusion reached today is satisfactory for us as a family.

‘It’s been a long five years.

‘My mother wasn’t just a mother, she was obviously a wife, a sister, a daughter, a great friend, and very recently a grandmother as well.

‘We can only look at this day as a moment of relief and final closure on what has been a hard chapter for us all.’

Timeline to tragedy

Mar 25, 2019 – Enid Heap, 84, admitted to Manchester Royal Infirmary with complications of chronic lung disease

Apr 15 – Beverley Sowah, 57, admitted to Manchester Royal Infirmary with terminal cancer

Apr 17 – BS is served a chicken mayonnaise sandwich

April 18 – EH is served chicken mayonnaise sandwich on the ward

Apr 26 – Beverley Sowah is diagnosed with a listeria-related infection and dies later that day

May 3 – EH diagnosed with listeria infection; 81-year-old Brenda Elmer discharged home after a stay at St Richard’s Hospital, Chichester

May 6 – Enid Heap dies

May 7 – first ‘outbreak meeting’ held at Manchester Royal Infirmary (MRI) in bid to trace source.

May 15 – Ian Hitchcock, 52, admitted to Royal Derby Hospital with advanced cancer

May 16 – Public Health England notifies MRI that tests have linked the strains of listeria which infected Mrs Sowah and Mrs Heap

May 24 – Public Health England identifies the infected patients all ate sandwiches supplied by Good Food Chain

May 25 – all hospitals told to withdraw Good Food Chain sandwiches

Jun 2 – after deteriorating at home, Mrs Elmer is admitted to Tunbridge Wells Hospital + diagnosed with listeria infection

Jun 7 – Public Health England goes public about outbreak after establishing North Country Cooked Meat as the source, saying there have been six listeria infection cases and three deaths

Jun 8 – Mr Hitchcock dies at Nottingham City Hospital

Jun 14 – Public Health England reveals the number of cases of infection has risen to nine with five deaths in total

Jun 17 – Health Secretary Matt Hancock reveals patients were infected at eight hospitals across England and promises a ‘root and branch’ review of NHS hospital food

Jul 17 – Mrs Elmer dies at Tunbridge Wells Hospital

Post source: Daily mail

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