Two women died after eating chicken mayo sandwiches fed to them in hospital and contaminated with listeria, an inquest has concluded.

Retired Jamaican nurse Beverley Sowah, 57, and mother-of-five Enid Heap, 84, were given the sandwiches on successive days while patients at Manchester Royal Infirmary (MRI) in 2019.

Both women, who both had underlying health problems, died within days, the joint inquest into the death of the women heard at Manchester Coroner’s Court.

Their deaths were among seven fatalities, part of a nationwide alert over the listeria outbreak which affected nine people in all in other hospitals, including in Liverpool, Leicester and Derby.

Listeria can cause an illness called listeriosis, which can be fatal for people with weakened immune systems, including the elderly, sick or children.

Manchester Royal Infirmary inquest
Enid Heap, who was one of two women who died after eating chicken mayo sandwiches given to them at Manchester Royal Infirmary (Alistair Heap/PA Media)

Following a five-day inquest, a jury concluded the listeria bacteria entered the food chain at cooked meat processing firm North Country Quality Foods in Salford, Greater Manchester.

They supplied the contaminated chicken to sandwich-making firm the Good Food Chain, based in Stone, Staffordshire, which used it to produce chicken mayo sandwiches.

These were then supplied to Sodexo, who were contracted to supply the NHS trust running the MRI, and the sandwiches were fed to Mrs Sowah and Mrs Heap.

Both women acquired listeria from the contaminated food which more than minimally contributed to their deaths, jurors decided.

The cause of death for Mrs Sowah was given as sepsis, listeria and metastatic breast cancer. For Ms Heap the cause of death was given as septicaemia, listeria, pneumonia and pulmonary fibrosis.

Jamaican-born Mrs Sowah was admitted to the MRI on April 15 2019, at the time she was suffering from advanced breast cancer. Two days later she was given the chicken mayo sandwich and died on April 26.

Mrs Heap, a retired chemist shop assistant, was admitted to the MRI on March 25 2019 and was served the same type of sandwich on April 18. She died on May 6.

After the inquest concluded Manchester city coroner Zak Golombeck told the families: “I hope in time you can all remember your loved ones for the happy memories that you all spent together.”

Alistair Heap, Mrs Heap’s son, said her family were grateful to know the sequence of events that led to her death.

He added: “We lost her more than five years ago, and our grief at her loss was exacerbated when we were informed that her death was linked to listeria reported to have come from a sandwich consumed whilst she was in hospital.

“We are also grateful that the case has highlighted the importance that businesses involved in food processing should maintain a strict standard of care and be subject to rigorous testing when supplying foods to the public, particularly to vulnerable groups in hospital environments.”

Earlier the inquest heard North Country Quality Foods (NCQF) was found to be the earliest point in the supply chain where listeria matching the outbreak strain was detected, with their chicken supplied to the Good Food Chain (GFC) the sandwich makers.

The Good Food Chain made up to 40,000 sandwiches a day, supplying around 70 hospitals.

The inquest heard there are safe levels of listeria and it is a widespread, common bacteria, with various different strains, with the legal limit of 100 cfu/g (colony-forming units per gram).

A month after the women’s deaths, as public health officials investigated, a sealed bag of chicken products supplied from NCQF to GFC was tested and found to have an “unprecedented high level” of the same strain of listeria involved in the outbreak.

The level of listeria found in the diced chicken bag was 1000 cfu/g, 10 times the legal limit.

Also, another customer of NQCF had a supply of bacon from them which when tested also had the outbreak strain of listeria involved in the hospital deaths.

Public health investigations immediately linked the two MRI deaths because they were at the same hospital and both patients had consumed the same sandwiches.

They then worked backwards to source the sandwich supplier and who had supplied the meat for the sandwiches.

Both meat supplier and sandwich maker firms have since gone into liquidation.