An NHS trust that gave four newborn babies contaminated feed has admitted that it was operating “an entirely unsafe system” at the time they became infected. The admission came during evidence by a senior doctor at Guy’s and St Thomas’ trust (GSTT), who led its investigation into the outbreak, during an inquest into how one of the very premature babies died. Dr William Newsholme was answering questions last week at the inquest at Southwark coroner’s court in London into the death of Aviva Otte at St Thomas’ hospital on 2 January 2014. Newsholme was questioned about why the results of tests carried out on samples of the baby feed on 26 December 2013 did not come back until 6 January, by which time the baby had died and three others were ill. He was asked if he would agree that the long delay meant that “that this is an entirely unsafe system within which to be preparing parenteral nutrition for the most vulnerable cohort of patients in your hospital”. Newsholme, a consultant in infectious diseases and the trust’s clinical lead for infection prevention and control, answered: “Yes, I would.” The inquest is examining events surrounding the deaths of Aviva and of two other babies, nine day-old Yousef Al-Kharboush and one-month-old Oscar Barker, in an outbreak of Bacillus cereus five months later which also involved contaminated feed. Nineteen babies at nine hospitals were infected in that outbreak, three of whom died. The inquest also heard that at the time of the first outbreak Eileen Sills, GSTT’s chief nurse, voiced concern to colleagues about a delay in alerting the infection control department to it and asked if they should have acted faster. The recipients included Amanda Pritchard, who at the time was GSTT’s chief operating officer and has since become the chief executive of NHS England. In her email on 17 January 2014 she asked them: “As part of the investigation could I ask you to look at when you highlighted the problem between the 24th Dec and 2nd January, did you or should you have escalated to infection control to assess risk before we found ourselves with an outbreak in NNU [neonatal unit]?” Newsholme told the court that, given the trust’s need to know about the outbreak and act to limit its impact, “this is an entirely appropriate question for her [Sills] to ask”. In 2022 the Guardian revealed that the first outbreak had occurred and that GSTT had never publicly disclosed that, despite four very vulnerable newborns being infected. Earlier this month Dr Grenville Fox, another senior doctor at GSTT, who had treated Aviva, told the inquest that she had indeed died as a direct result of the contaminated feed, which contradicted the trust’s insistence for more than 10 years that her death was due to “natural causes”. Asked in court last week why the “root cause analysis” report of his investigation into the first outbreak did not mention that one of the four infected babies had died, Newsholme said that that was “an unfortunate omission”, which he did not explain. His report said only that four patients had become ill during the outbreak, of whom “three were felt to have moderate clinical deterioration”. He was also asked why GSTT had put together a “holding statement” to be given to any journalist who inquired about the first outbreak, but had not alerted the media that they were dealing with an outbreak of Bacillus cereus, a potentially fatal infection. In reply he told the court that “this is not any form of obfuscation or cover-up”. Giving evidence two weeks ago, another GSTT doctor, Anthony Kaiser, told the coroner, Dr Julian Morris, that the trust’s handling of the outbreak, which it kept secret, was “not a cover-up”. Aviva’s mother, Jedidajah, is a Guardian journalist. The inquest continues.