Laura Farmer

UCLH Trust response to PFD

The UCLH Trust response has been led by the Division of Infection, in recognition that the concerns raised 
by the coroner were principally about communication about the STEC outbreak investigation between 
UKHSA and the patient and family, a topic for which our Infection Prevention and Control (IPC) teams form 
the Trust’s local expertise and point of contact, although a community outbreak investigation does not fall 
directly within their scope of practice.

We have sought input from microbiology and IPC colleagues as well as from our haematology team who 
lead on management of HUS/TTP and looked after the patient; and from the nursing leadership of the 
Intensive Care Unit.

We look forward to seeing the PFD response from UKHSA to understand if there is anything further that 
UCLH as a Trust can do in future to support issues to do with STEC outbreak investigations that involve our 
patients, as we are a national centre for TTP.

We recognise that it can be a challenge for patients and their families, as well as for the clinical teams 
looking after them, to provide to health protection teams the important information needed for an 
outbreak response. This is because the patients are ill, and because there are lots of inherent uncertainties 
in outbreak investigations. It is also important that there is some documentation in our electronic health 
records system (EHRS) that the health protection team have contacted the patient (see below). If the HP 
team visit then the UCLH nurses are generally happy to document this on EHRS and can certainly document 
a contact number for the HP team for ongoing queries; if it is a telephone contact that can be more difficult 
to implement as standard practice but we would endeavour to do so, hoping that the health protection 
team will encourage the UCLH staff to do so, in parallel 

When patients are hospitalised, the health protection teams know to phone the nurse-in-charge of the 
ward (for HUS/TTP cases this is usually but not always ICU), to establish whether the patient is well enough 
to cope with a telephone call to go through the questions required for a timely outbreak investigation. Our 
nursing colleagues have reassured us that they always endeavour to support these consultations when they 
believe the patient is well enough to undertake the discussion, and exercise their expert judgment in 
supporting patients and their families as compassionate carers in this regard, if necessary involving the 
medical team in this decision.

Our IPC nurses’ normal practice is to review actively infectious patients including e.g. with STEC on our 
wards and liaise with clinical ward staff. In addition, IPC nurses  can explain what the infection means to 
patients and their families, especially if the patient/family requests such information, including how 
outbreak investigations generally proceed. This may include signposting them to the appropriate UKHSA 
patient info leaflets and how to contact the relevant health protection team for ongoing queries, and 
document this in the notes. We will reflect on this case and reinforce how we make relevant infection 
information available to patients and their next of kin, having clarified from UKHSA colleagues that the 
appropriate link to relevant patient information leaflets is on pages 59-66  of this document: https://
assets.publishing.service.gov.uk/media/63b84426d3bf7f26359c13b2/health-guidance-shiga-toxin-
producing-escherichia-coli.pdf

Prevention of Future Deaths 
Report (Regulation 28): 
UKHSA’s response 

UKHSA’s response to PFD 2024-0496 Laura Farmer: Prevention of Future Deaths Report  - 
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 UKHSA would like to start this response by expressing our deepest sympathies to 
the family of Laura Farmer. 

Background  

1.  On 16 September 2024, UKHSA received a Prevention of Future Deaths (PFD) 
report from Senior Coroner Mary Hassell, Inner North London St Pancras 
Coroner’s Court. The PFD report was issued after an inquest into the death of 
Mrs Laura Farmer. UKHSA had not been invited to provide evidence at the 
inquest, nor were UKHSA officials notified that an inquest was taking 
place. UKHSA was therefore unable to provide important information to assist 
the Senior Coroner in preparing her findings. UKHSA’s response sets out details 
which it considers relevant, including its investigations concerning Laura Farmer, 
to provide the Senior Coroner with a full picture. The response also addresses 
concerns raised by the Senior Coroner in the PFD report. 

UKHSA’s role in outbreak management 

2.  UKHSA’s primary objective in outbreak management is to protect public health: 
by identifying the source and cause of infection and transmission dynamics, and 
by implementing control measures to prevent further spread or recurrence. It is 
not within UKHSA’s remit to investigate the death of an individual. The roles of 
UKHSA and key external stakeholders in outbreak management, including the 
Food Standards Agency (FSA), the Medicines and Healthcare Products 
Regulatory Agency (MHRA), local government and NHS England are 
complementary. In practice these organisations work closely as part of a single 
public health system to deliver effective protection for the population from health 
threats. The regional UKHSA team (also known as health protection team, HPT) 
will investigate the public health outbreak/hazard (as opposed to individual 
deaths), help identify the source and provide local health protection services, 
expertise, response and advice to partners. UKHSA has a coordination and 
advisory role primarily, supporting for example, the FSA, MHRA and NHS 
England in leading their own investigations. 

Shiga toxin producing Escherichia coli (STEC) 

3.  STEC, also known as Vero cytotoxin-producing Escherichia coli (VTEC), are 
bacteria that can cause gastroenteritis. Symptoms vary from mild to bloody 
diarrhoea and, in severe cases, can cause haemolytic uraemic syndrome (HUS), 
a serious and life-threatening condition predominantly affecting the kidneys. A 
small proportion of patients, mainly children, develop haemolytic uraemic 
syndrome (HUS) (1).  

4.  The main reservoir for STEC is cattle although it is also carried by other 

ruminants such as sheep, goats and deer. Transmission can occur through direct 
or indirect contact with animals or their environments, consumption of 
contaminated food or water, and person-to-person spread. STEC infections can 
present as sporadic cases or as outbreaks. Recent outbreaks have been 

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 associated with beef products, cucumber, watermelon, watercress, salad leaves, 
unpasteurised cheese and ready to eat sandwiches. 

5.  Household transmission can occur, but it is rare to observe household 

transmission outside of those with children under the age of five or those who are 
unable to maintain adequate personal hygiene. 

Investigation of cases and clusters of STEC 

6.  Diagnostic laboratories are required to notify UKHSA once identification of STEC 

has been made, in accordance with The Health Protection (Notification) 
Regulations 2010. Similarly, cases where there is a clinical suspicion of HUS, 
regardless of whether there is microbiological evidence of an infectious cause, 
should be notified to the Proper Officer of the local authority to allow prompt 
investigation and action. In most cases, local authorities appoint a consultant in 
communicable disease/health protection based within UKHSA regional teams as 
their Proper Officers. 

7.  All STEC cases are investigated as per UKHSA’s Operational Guidance for STEC 
(Shiga toxin-producing Escherichia coli: public health management - GOV.UK 
(www.gov.uk). The aim of the public health investigation of individual cases is to 
prevent onward transmission and to gather risk factor information to identify and 
control sources of infection.  

8.  On notification UKHSA arranges for an enhanced surveillance questionnaire 

(ESQ) to be completed to obtain a detailed history of exposures seven days prior 
to onset of illness. The ESQ collects demographic details, risk status, clinical 
conditions and exposures including travel, food and water consumption, 
environmental exposures, contact with animals and outbreak status. The full 
questionnaire is available at: Shiga toxin-producing Escherichia coli: 
questionnaire - GOV.UK (www.gov.uk). 

9.  In cases where there are people in the household aged five and under, or those 
who are unable to perform adequate personal hygiene or who work in high-risk 
settings (for instance handling food or working with young children) UKHSA or the 
local authority team may recommend additional testing or exclusion from work or 
childcare. 

10. For the vast majority of single cases, it is not possible to identify a specific source 

of infection despite thorough investigation. 

11. UKHSA works in partnership with local authority environmental health teams and 
other relevant agencies (for instance the FSA) to undertake these investigations. 

12. Completed ESQs are reviewed by UKHSA regional teams and used to inform 

action. They are also submitted to the national Gastrointestinal Infections, Food 
Safety and One Health (GIFSOH) Division within UKHSA to be included in the 
national enhanced surveillance system for STEC (NESSS), which combines 
microbiological, clinical and exposure information and is routinely used to check 
for links between cases. 

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 13. All samples which are positive for STEC at frontline diagnostic laboratories are 
referred for confirmation and typing using whole genome sequencing (WGS) at 
the national reference laboratory. 

14. Routine analysis of WGS data by the GIFSOH team is used to identify genomic 

clusters, defined as two or more cases with the same STEC strain.  

15. Overall, around 1500 cases of STEC are reported in England every year, with 

between 250 and 450 clusters detected, the majority of which (~80%) are small at 
five cases or less. UKHSA’s Operational Guidance for STEC is followed when 
assessing these clusters. Despite thorough multi-agency investigations, for 
foodborne outbreaks it is not always possible to identify the vehicle of infection or 
confirm the source of contamination. In 2021, of the four national investigations 
into foodborne STEC outbreaks, suspected vehicles were identified in two (pasta 
pots and watermelons) and it was not possible to identify a vehicle for the other 
two: (https://www.gov.uk/government/publications/escherichia-coli-e-coli-o157-
annual-totals/shiga-toxin-producing-escherichia-coli-stec-data-2021). 

Investigation of STEC infection in Laura Farmer (timeline) 

16. UKHSA understands that on 24 April 2024 Mrs Farmer was admitted to University 
College London Hospitals (UCLH), having been transferred from Royal Surrey 
County Hospital with HUS following a history of four days of diarrhoeal illness ten 
days prior to admission. 

17. On the same day, UKHSA London was informed that Mrs Farmer had tested 
positive for STEC (using polymerase chain reaction testing). UKHSA London 
immediately transferred Mrs Farmer’s details to UKHSA South East for follow-up 
as a resident of the South East region. 

18. On 25 April 2024 UKHSA South East spoke with nursing staff on the Intensive 
Treatment Unit (ITU) at UCLH and determined that Mrs Farmer was present on 
the ward and was well enough to be interviewed by UKHSA South East about her 
condition. UKHSA South East conducted the interview with Mrs Farmer by phone. 
This included undertaking an ESQ and gathering additional information to assess 
risk and to guide any recommended actions. 

19. Mrs Farmer reported that all household contacts were well at the time of 

interview. No close contacts were in risk groups for gastrointestinal (GI) infection. 
It was noted that no person in the household was aged five or under and no 
person in the household was reported as unable to perform personal hygiene. 
Risk of transmission in the household was considered low and no testing or 
further public health actions were recommended for the household as per 
national guidance. 

20. Infection prevention and control advice was provided verbally to Mrs Farmer at 
the time of the interview. UKHSA South East emailed Mrs Farmer after the 
interview confirming the advice and providing a factsheet, as per usual practice. 

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 21. Mrs Farmer was asked all questions on the ESQ, which included details of 

contact with water and animals as well as eating out and contact with people with 
a gastrointestinal infection. Mrs Farmer identified one restaurant, a trip to a city 
within in the UK for work (although no food was eaten on this trip), a blocked 
drain in the house, and contact with domestic pets. She also outlined foods she 
had consumed prior to becoming unwell. 

22. There were five specific details that Mrs Farmer was unsure of, and she 
requested that UKHSA South East send a follow up email outlining these 
questions so that she could ask her husband for more detail. This email was sent 
on the same day along with infection control advice.  

23. On 26 April 2024 UKHSA South East called Mrs Farmer to ask whether she had 
obtained the additional information from her husband but was unable to make 
contact. On 29 April 2024 after further unsuccessful contacts UKHSA South East 
called UCLH ITU and was advised that Mrs Farmer had sadly and unexpectedly 
died. 

24. The UKHSA staff member who made the follow-up call sought advice from senior 
colleagues at this time and it was agreed that no further contact should be made. 
UKHSA South East considered that the next of kin was grieving and that 
unnecessary contact could be considered intrusive at that time. UKHSA South 
East made the judgement not to speak to the next of kin on the basis that all 
public health actions had been completed, risk of ongoing transmission in the 
household was extremely low, both household contacts were well at the time of 
the interview, and that a significant time had elapsed since the onset of illness in 
Mrs Farmer. 

25. On 29 April 2024 UKHSA South East uploaded the completed ESQ to its clinical 
information system and shared the completed ESQ with the local authority 
environmental health team for follow-up and risk assessment of specific settings. 
The environmental health team were advised that Mrs Farmer had died and were 
requested not to contact Mrs Farmer’s next of kin. The environmental health team 
agreed to undertake a routine inspection of a restaurant attended by Mrs Farmer 
and conducted a risk assessment of other possible sources identified in the 
completed ESQ. 

26. UKHSA South East also sent the completed ESQ to UKHSA’s national GIFSOH 
team to review against exposure information for other cases. No other cases 
were identified with common exposures. 

27. On 2 May 2024 the WGS result became available and the STEC subtype causing 
Mrs Farmer's illness was identified as STEC O26:H11. At the time three other 
cases were microbiologically linked (using WGS) to this case. UKHSA’s GIFSOH 
team did a detailed review of the information available for these four cases and 
did not find any common links between these cases at the time nor any likely 
source of infection. 

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 Contact with Mrs Farmer’s next of kin  

28. On 14 June 2024 UKHSA South East was contacted by Waverly Borough 

Council’s environmental health team reporting that Mrs Farmer’s next of kin had 
attended their offices on 13 June 2024 requesting further information on the 
investigation of Mrs Farmer’s illness. The next of kin informed the environmental 
health officer that they had subsequently been unwell with diarrhoea after Mrs 
Farmer’s death. As a precaution the environmental health officer arranged testing 
of the next of kin and their household. 

29. On 14 June 2024 a UKHSA South East senior clinician called the next of kin to 

discuss their concerns further. The discussion included the role of UKHSA in case 
investigation, the timeline of actions taken by UKHSA following notification of Mrs 
Farmer’s illness and the next of kin’s concerns regarding lack of contact with 
them.  The next of kin was advised that Mrs Farmer’s illness was unrelated to any 
current or previous outbreaks of STEC.  It was agreed that UKHSA would discuss 
the next of kin’s concerns regarding contact with them in their next team clinical 
review to ensure any lessons were identified. It was also agreed that UKHSA 
would send the questionnaire to the next of kin for further completion.  

30. On 14 June 2024 UKHSA South East sent the next of kin a copy of the ESQ 
previously completed with Mrs Farmer, asking for any helpful or relevant 
information to be added and emailed back to UKHSA South East. Information on 
UKHSA’s complaints procedure was also shared by email. 

31. On 20 June 2024 the results of the testing of the next of kin and their household 
were communicated to the next of kin and household by text – all results were 
negative. 

32. There was no further contact between UKHSA South East and the next of kin. 

Response to specific concerns raised by the Senior Coroner 

Chief Coroner’s Guidance 

33. In accordance with the Chief Coroner’s Guidance, Guidance No. 5 Reports to 

Prevent Future Deaths, there is a pre-condition that “the coroner has considered 
all the documents, evidence and information that in the opinion of the coroner is 
relevant to the investigation” (Regulation 28(3)). UKHSA acknowledges from the 
PFD report that the Senior Coroner did not call anyone from UKHSA to give 
evidence as she “expected UKHSA to have shared relevant information with both 
clinicians and family.” We would respectfully draw attention to the fact that if 
UKHSA officials had been contacted, invited or UKHSA itself requested to be an 
Interested Person, we would have been able to provide the Senior Coroner with a 
more in-depth understanding of UKHSA’s involvement, thus, making available 
additional evidence and documentation on which to base her recommendations. 
Without having the full extent of UKHSA’s investigations at her disposal, our view 
is that not all the relevant evidence was considered. This may have gone some 
way into shaping the Senior Coroner’s overall recommendations. 

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 34. We acknowledge the Senior Coroner’s expectation that UKHSA share relevant 
information with both clinicians and the family. However, without information 
about our role or any UKHSA representation at the inquest, we believe this 
expectation has led to an unfair observation. Paragraph 25 of The Chief 
Coroner’s Guidance Note No.5 states that a Coroner, when reporting, should 
“…base their report on clear evidence at the inquest or on clear information 
during the investigation, to express clearly and simply what that information or 
evidence is, and to ensure that a bereaved family’s expectations are not raised 
unrealistically.” The lack of UKHSA evidence and representation at the inquest, in 
our view, would cause difficulty in expressing clearly and simply when, how and 
who information should have been disseminated to. This in turn would lead to 
bereaved family members relying on incorrect information and unfortunately 
believing dissemination processes were in place that were not in accordance with 
UKHSA’s policies and procedures.   

Review of practice 

35. UKHSA is a learning organisation and commits to undertaking regular reviews of 
practice and ensuring learning is identified to support quality improvement. 

36. UKHSA South East undertook an informal peer review of actions taken. The 

review concluded that all public health action had been completed for this case in 
line with the national guidance and standard practice and that the team had acted 
compassionately in their interactions with Mrs Farmer and subsequently with the 
next of kin.  

37. It was concluded that it was appropriate for the team to speak directly with Mrs 

Farmer in this instance. The clinical team providing care to the patient confirmed 
that Mrs Farmer was well enough to speak to the UKHSA staff member at the 
time of the call and Mrs Farmer consented to the interview. She was assessed by 
the experienced UKHSA nurse administering the ESQ to be alert and well 
enough to complete the process. It is always preferable to undertake a risk 
assessment directly with the case if possible. 

38. UKHSA South East asked all the questions contained in the ESQ, which includes 

a detailed food history as well as contact with animals and water. The 
investigation undertaken by the team was in line with national guidance and 
consistent with best practice. It should be noted that in many instances it is not 
possible to identify the source of infection for individuals and investigations can 
be lengthy and complex. 

39. Infection prevention control advice was provided directly to Mrs Farmer at the 
time of interview.  It was judged at the time that there was very low risk of 
infection to the household contacts therefore no further action was taken in line 
with national guidance and usual practice. 

40. When UKHSA became aware that the next of kin had ongoing concerns about 

the management of this case, a senior member of the regional team made direct 
contact to provide additional information and answer questions raised. 

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 41. The review identified one learning point in relation to dealing with unwell cases, 
namely that where a case is known to die during investigation a risk assessment 
should be undertaken in collaboration with the clinical team treating the case to 
determine whether additional contact should be made with the next of kin. Any 
consideration of the need for a grieving family for privacy should be weighed 
against the potential need for information. The contact details of the UKHSA 
regional team will be shared with immediate family so they can contact the 
regional team if they have any questions or would like to provide any further 
information. 

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