“First Concern 1”

The coroner’s concerns

– First Concern 1. Mrs Elmer attended St Richards Hospital, Chichester, for elective surgery. She had attended the hosptial for a Pre Operation Assessment on 25th April 2019 and was admitted for her surgery on 30th April 2019. Whilst attending the hospital she acquired a Listeria infection from a chicken sandwich although this was not know at the time. Mr Elmer did not live in Sussex and following her treatment she returned home to Kent on 3rd May 2019. 2. Western Sussex Hosptial Trust, NHS England and Public Health England (PHE) first become aware of a possible outbreak on Listeria on 19th May 2019 when blood cultures from another patient ast the Worthing Hospital site confirmed a listeria infection. On 26th May 2019 NHS England notified all hosptials of a national outbreak of Listeria and a possible link to sandwiches that has been provided by the Good Food Company, a supplier to a number of Trusts. 3. Whilst it was accepted that details of the possible outbreak were shared locally with other medical professionals (and therefore there was a local knowledge of the Listeria outbreak) there did not appear to be any attempt by NHS England or PHE (by way of a Public Health message) to communicate with those patients who were treated within the Trust but who were now out of the area in different parts of the Country. 4. It was unfortunately that when Mrs Elmer fell ill, neither her GP who initially treated her, nor her family had any idea that her illness may be connected to the Listeria outbreak. This meant that she was not prioritised for a blood test and this delayed her being treated appropriately for Listeriosis. This diagnosis was only made when she was admitted to Tunbridge Wells Hospital, her local hospital in Kent following an emergency admission. It is unknown whether earlier treatment would have changed the outcome but it may have eased Mrs Elmer’s sufferning. 5. Consideration needs to be given to how communications should be disseminated following such an outbreak so that as many patients as possible, who had been in the hospital at the relevant time, are made aware and can seek medical assistance if they become unwell. Second Concern. 1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboraties who identifiy Listeria in food to share the Listeria isolate with PHE or indeed keep this isoloate for any period of time. If a problem is subsequentlhy identified 2 by PHE then it makes it particulary difficult to check if particular products have been implicated. 2. Similary there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier. 3. In both these circumcumstances this leads to missed opportunities to deal with any outbreak.

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, 2020-0159

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0