Recurance · prevention of future deaths reports
Pre-inquest brief
Inaccurate risk assessment of Mycobacterium Chimaera infection from heater-cool
The earlier warning
Nicholas Winterton · 31 Mar 2021 · Alison Hewitt, City of London
“It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate”
What was promised
Stated action 1 · response to Nicholas Winterton (31 Mar 2021) · stated timescale: September 2021
“PHE will further update the risk estimates and ensure that these are published by September 2021”
judiciary.uk/…/2021-0204-Response-from-Public-Health-England-Re…
What recurred
- 29 Jun 2023 · Clinton Fear · Simon Fox · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Nicholas Winterton · 31 Mar 2021
“It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate”
Later · Clinton Fear · 29 Jun 2023
“There is an inconsistency between - Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection”
What happened next
No web check of the stated actions has been published for this chain.