“That no source of contamination could be identified due to the infusion set, filter…”
Dated 11 Dec 2025, from the coroner for South London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 5 Feb 2026. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated11 Dec 2025
- Deadline5 Feb 2026
- Published on judiciary.uk18 Dec 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “[REDACTED], Chief Executive, Medicines and Healthcare Products Regulatory Agency (MHRA)” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation. , expert pharmacist and pharmaceutical regulator drew attention to a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN). b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management. c) The use of 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and BBraun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance. d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies. e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0620
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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