All of the feeds which could be contaminated have since been recalled and regulators stressed that it was unlikely any were still in use as the batch has passed its use-by date. Last night paediatric doctors said the contamination was "every parent's worst nightmare" and that urgent action must be taken to improve the safety of processes to produce such nutrition.
Regulators said because the blood poisoning, caused by a common bacterium known as Bacillus cereus, develops quickly they were not anticipating further cases, although this could not be ruled out. The 15 babies were being treated in six neonatal intensive care units and many had been born prematurely.
The newborn died on Sunday at Guy's and St Thomas' Hospital, which is treating two other cases. Adam Finn, professor of paediatrics, University of Bristol, said: "When a medicine makes patients sick, it is everyone's worst nightmare. This contamination incident seems to have been detected quickly but, tragically, not quickly enough to save a life lost. Having stopped the outbreak, the next priority will be to understand how it came to happen and ensure it cannot recur."
The newborns, most of whom were premature, were being fed through a tube into their bloodstream because they were too poorly to be mouth fed.
Public Health England (PHE) and the Medicines and Healthcare Products Regulatory Agency (MHRA) have launched an investigation.
All neonatal intensive care units in the country have been informed and a recall has been issued for any remaining batches of the liquid feed.
The first case appeared at Chelsea and Westminster hospital on Saturday and then other London hospitals began to see cases over the weekend. It was thought to have been caused by infected bedding or similar products used locally until cases began appearing elsewhere on Monday and Tuesday.
The final cases at Luton were diagnosed early yesterday and investigations soon identified the feed as the likely cause, a spokesman for Public Health England said. An incident at the manufacturing plant is thought to have been the source of accidental contamination and inspectors will visit the plant run by ITH Pharma Ltd.
The company, based in London, was founded by Adam Bloom and Karen Hamling, both trained pharmacists.
Bacillus cereus is a bacteria found widely in the environment in dust, soil and vegetation. Most surfaces would be likely to test positive for its presence. Adam Burgess, the MHRA's manager of the Defective Medicines Reporting Centre, said: "We have sent inspectors to the manufacturer's facility to carry out a detailed and rigorous inspection and we have ensured that the potentially affected medicine is recalled." Dr Susan Hill, a consultant paediatric gastroenterologist said: "This is a life-saving treatment for babies who are born very prematurely or with a severe gut problem. Any challenge to their immune system can be life-threatening."
A spokesman for Guy's and St Thomas's Trust said: "All babies on the unit are being screened for the bacterium as a precaution and enhanced infection control measures have been put in place to prevent any further cases. These enhanced measures will remain in place until the trust is satisfied that no other babies are at risk."
