A hospital has overhauled its ward drainage system after a teenager contracted a rare water borne fungal infection while being treated for Acute Myeloid Leukaemia.
Thirteen-year-old Tatiana Stankovic-Davis had been admitted to Bristol Children’s Hospital in the spring of 2017 for treatment for leukaemia.
But while in the hospital and staying on ward 35 she contracted the rare fungal infection Fusarium.
The infection is so rare that there have been less than 100 cases recorded in the UK.
(Image: Dave Betts)
An inquest heard that although the infection lives widely in the normal environment, if contracted by a patient with a compromised immune system in 80 per cent of cases it can prove fatal.
The hearing at Avon Coroners Court heard how Tatiana – described by her family as a ‘beautiful red headed Lego loving girl who was brave and resilient’ – was diagnosed with a rare cancerous tumour in her bladder in March 2015.
Tatiana, who was partially deaf, underwent surgery followed by chemotherapy and radiotherapy treatment which resulted in her losing her hearing altogether.
During 2015 and 2016 Tatiana was in remission and had regular check-ups at hospital and started secondary school.
In December 2016 she underwent routine surgery on her left foot followed by a routine MRI scan in January 2017 which said she was clear of cancer.
However later that same month Tatiana started to suffer with swollen gums.
Blood tests and x rays revealed the devastating news that that the teenager had developed therapy related Acute Myeloid Leukaemia (AML).
She underwent further chemotherapy treatment and told that the only hope of a cure was a bone marrow treatment.
The inquest heard that any relapse of her AML could prevent any transplant.
In March that year, while in hospital, Tatiana developed the fungal infection Fusarium for which she was treated with antibiotics and anti-fungal medication.
Then, in July, Tatiana relapsed where it was discovered her AML had returned.
Tatiana continued to receive palliative chemotherapy treatment. Although she responded well to the treatment she suffered nasty side effects, including continued sickness and diahorrea.
However a bone marrow treatment was ruled out due to the fact that the match found was not 100 per cent perfect, the risk that she could still have a Fusarium infection and her current weakened condition due to her previous tumour.
Mum Nada said: “I asked Tatiana if she wanted to go through any more chemotherapy.
“However she was adamant she would tolerate more and kept saying she did not want to die.”
After undergoing further treatment and preparing to be discharged, Tatiana complained of a pain in her right hip when visiting the bathroom on the hospital ward on August 6.
Further tests revealed a fracture in her hip, which medics believed to be caused by the AML.
Dr John Moppett, paediatric haematologist said: “Bone marrow transplants for secondary AML are rarely successful due to the risk of relapse.”
Doctors discounted surgery and instead decided to put her in traction and gave her morphine followed by the drug Zoledronic Acid to help reduce her pain.
However soon after the treatment she became unwell, with a distended stomach and fluid on her lungs.
At that time there was no evidence that the AML had returned.
Sadly her condition continued to deteriorate and Tatiana died at 3.45am on August 23 with her parents by her side.
A post-mortem examination was carried out 15 days after her death.
The report was reviewed by Dr Andrew Bamber, a paediatric consultant in pathology on the request of senior coroner for Avon Maria Voisin as part of the inquiry.
The post mortem revealed Tatiana’s AML had spread and there were masses of AML cells in her liver, abdomen and lungs.
However Dr Bamber added he could find no firm evidence of a Fusarium infection – or any other infection – at the time of her death.
But the post mortem did reveal that Tatiana had previously undiagnosed Hypertrophic Cardio Myopathy.
He said that although this was not a main cause of her death, he ruled it was a contributory factor.
The main cause of death was given as therapy-related Acute Myeloid Leukaemia.
The inquest heard after Tatiana’s death, infection control at the hospital had carried out a full review of ward 35.
Issues with the drainage of the showers on the ward was identified and swabs taken revealed Fusarium was present in 80 per cent of the shower trays and drainage system and in the air vents.
The affected cubicles were closed and improvements to the drainage and showers were carried out to stop water collecting.
A new cleaning regime was introduced along with a move to filter air through the vents to reduce the risk of fungal infections.
The inquest heard that as Fusarium was such a rare infection there were no National standards for guarding against it.
University Hospitals Bristol NHS Foundation Trust clinical chair for womens’ and children’s services Bryony Strachan told the inquest: “The cleaning regime was to the standard of any ward.
“The new cleaning regime was a precautionary measure to go above that standard.
“There are no national standards regarding Fusarium so we took a belt and braces approach.
“Fusarium is an extremely rare infection and it was our first ever case at the hospital.”
Senior coroner for Avon Maria Voisin recorded a conclusion that Tatiana died from natural causes.
A University Hospitals Bristol NHS Foundation Trust spokesperson said: “We would once again like to offer our condolences to Tatiana’s family and friends.
“Today’s inquest concluded that Tatiana died due to natural causes, and we hope that this independent process has provided her family with answers to any questions that they had.”
(Image: Dave Betts)
“Our thoughts remain with Tatiana’s family and friends on what has no doubt been a very difficult day for everyone involved.”
Tatiana, who friends said was ‘kind to everyone she met’ had raised nearly £20,000 while poorly to pay for new toys for children on hospital wards across the UK.
Consistently providing toys for children undergoing chemotherapy is costly, as strict infection control rules mean few toys can be reused.
A Lego fanatic, the remarkable 13-year-old wanted to share the joy of the little plastic bricks and their powers of distraction during her treatment.
Tatiana, helped by dad Simon, raised the money alongside the charity Fairy Bricks – a small organisation set up by three Lego enthusiasts with the aim of putting Lego in the hands of children in hospitals.
Tatiana was posthumously awarded a Lord Mayor’s medal as well as a plethora of other awards for her fundraising exploits.
She and dad Simon were also honoured by the Prime Minister last year with a Points of Lights Award for their efforts.