On 15 November 2011 commenced an investigation into the death of Hope Erin Evans The investigation concluded at the end of the inquest on 16 July 2014_ The medical cause of death is Ia Sepsis 1b ESBL E. coli in a premature The conclusion of the inquest as how Hope came to her death is & narrative one and is as follows: - Hope died from sepsis contributed to by the ESBL E coli which was contracted in hospital after being born prematurely at 26 weeks The source of the ESBL E. coli is likely to have been from another baby but the means of transfer is unknown_

The deceased was Hope Erin Evans and she died at 1.00 a.m. on 4 November 2011 at Singleton Hospital Sketty Swansea. Tests confirmed that baby Hope and baby A1 and baby A2 to have had the same strain of the ESBL E.coli. The outbreak management group therefore concluded that the ESBL E.coli was probably transmitted between the babies_ Mother A had received private IVF treatment abroad and received a twin pregnancy: Mother A contracted ESB L E: coli although it is unclear how this was contracted This was reflected as a positive ESB L E. coli result and identified in Mother A's medical notes from abroad which she had in her possession and declared them several days after the outbreak_ Mother A was transferred from Prince Charles's Hospital Merthyr to Singleton Hospital Swansea due to premature labour and spontaneous rupture of membranes_ Where there are transfers between hospitals the All Wales Inter Hospital Transfer documentation baby should be completed and sent with the women's documentation to the receiving hospital. This documentation has the potential to alert staff to risk factors although there is no specific question relating to women having treatment abroad or having contracted an alert organism. There is no evidence to suggest that this document was completed and sent to Singleton Hospital nor was it requested by anyone at Singleton. All three babies were delivered by Caesarean section on the same (31st of October 2011) in the same theatre and were transported to the ITU in the Neonatal ward. The babies were placed in cots in close proximity to each other in the ITU unit At the time the neonatal unit ITU environment was poor with evidence of dated facilities The number of sinks within the area was inadequate for the number of cots in use at the time of the outbreak The spacing of cots did not meet current standard The Neonatal ward has undergone substantial refurbishment to ensure more space around the cots and improved hand washing facilities_ Screening for ESPN L E: coli is not recommended routinely in UK neonatal units except under outbreak conditions_ The ESBL E. coli infection is becoming more frequent worldwide due to injudicious antibiotic use in the community and particularly in India and other countries where antibiotics are freely available over the counter: However recently pockets of infection are arising in this country_ It was not until around midday on 3 November that the microbiologist informed the Neo Natal unit of the results of mothers A's cultures (taken on the 29 October while mother A was at Prince Charles Hospital) showing ESBL E. coli:

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action

- Hope died from sepsis contributed to by the ESBL E coli which was contracted in hospital after being born prematurely at 26 weeks The source of the ESBL E. coli is likely to have been from another baby but the means of transfer is unknown_