Dr. William Newsholme admitted that the system for preparing parenteral nutrition for vulnerable newborns at GSTT was entirely unsafe, culminating in the tragic deaths.
Eileen Sills, GSTT's chief nurse, expressed concerns about alerting the infection control department too late in the process, questioning the response time to the outbreaks.
The inquest revealed that contaminated feed led to the infections of nineteen babies, with the deaths of Aviva Otte and others highlighting severe systemic failures.
The delay in the testing results for the contaminated baby feed, which took 11 days, compounded the unsafe environment threatening newborns' lives in the NICU.
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