In a letter to Health Secretary Wes Streeting he wrote: “In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.”
He also said that although issues must be reported to the NHS and the healthcare regulator the Care Quality Commission (CQC), “the threshold or necessity for such reporting appears unclear and, in essence, up to the trust”.
He added: “There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other trusts and commercial organisations.”
Dr Morris also highlighted that Bacillus cereus is resistant to some cleaning methods and that sporicides – disinfectants that kill microbial spores – can be required to achieve decontamination.
He said St Thomas’ Hospital knew this prior to the outbreak later that year but did not pass on its findings.
ITH Pharma was fined £1.2m by a crown court in 2022 after providing TPN from which 19 premature babies became infected across nine hospitals in 2014, including Oscar and Yousef.
The company pleaded guilty to a number of regulatory offences in 2022.
A spokesperson said the company welcomed the coroner’s recommendations and it “recognised the importance of sharing information and learning” across the industry.
“Any information that had been shared with ITH and the MHRA as a result of a previous outbreak in the NHS five months prior to the ITH incident could have been of real value in taking steps to prevent future possible incidents.”
Guy’s and St Thomas’ NHS Foundation Trust said following Aviva’s death, it ceased TPN production and began to outsource it.
Dr Sara Hanna, a medical director at Guy’s and St Thomas’ NHS Foundation Trust, said it extended its “deepest condolences” to the families of Aviva and Yousef.
“We are considering the coroner’s findings carefully and continue to ensure we are doing everything possible to provide the very highest quality of care for all of our patients, but particularly for our most vulnerable patients,” Dr Hanna added.
Recipients of the coroner’s letter, which also include NHS England, the MHRA and the CQC must respond to his report by 8 January next year.