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Two mums from Kent who died of herpes after giving birth could have been infected with the virus by the same surgeon, an investigation has found.
The doctor - a locum working for East Kent Hospitals - performed caesareans on Kimberly Sampson, from Whitstable, and Samantha Mulcahy, from Hawkinge, in 2018.
Both fell seriously ill in the days after and tragically died of HSV-1 - a common infection which typically causes sores around the mouth or genitals.
A private laboratory brought in by the Trust suspected the women had contracted the virus via "surgical contamination", but despite requests for East Kent Hospitals to provide a swab from the doctor who delivered the babies, none was ever produced.
The families of Kimberly, 29, and Samantha, 32, were also not informed the same surgeon and midwife had been involved in both C-sections, and were told there was no connection between the deaths.
Now, they are calling for inquests to be opened after BBC journalists uncovered details of the efforts made behind closed doors to establish any links between the tragedies.
Both women had died of HSV-1, but neither had a history of the virus, and tests showed it was the first time either had been infected with herpes.
Kimberly Sampson, a "bright and bubbly" barber and mum to a three-year-old daughter, lived at her mother's home in Newton Road, Whitstable.
After a smooth pregnancy, she went into labour at Margate's QEQM Hospital on May 3, 2018.
She experienced complications, and it was eventually decided to perform a C-section.
Baby Albie was delivered healthy, but Kimberly required a blood transfusion following the operation.
She was discharged with Albie two days later, at her request, but was in a lot of pain and barely able to walk.
Her condition deteriorated over the following days and she was eventually taken back to hospital by ambulance, where she was treated on the maternity ward for bacterial sepsis - a potentially fatal condition - with antibiotics.
But her condition continued to worsen, so she underwent a series of operations to identify and treat the infection.
Eight days after she was readmitted, a consultant microbiologist suggested trying the antiviral drug Aciclovir, which is used to treat herpes infections.
It was only after Kimberly was transferred to King's College Hospital in London that she was diagnosed with a catastrophic herpes infection.
She was given just "hours or days" to live and died on May 22.
Six weeks later, nursery nurse Samantha would die of the same virus at the William Harvey in Ashford, which is also run by East Kent Hospitals.
She had gone into labour four days before her due date, and after 17 hours of contractions and some concerning blood test results was taken for a C-section.
The operation was performed by the same doctor who had delivered Kimberly's baby.
Samantha's daughter was born healthily, but the new mum was kept in for observation because doctors were concerned about signs of the blood pressure condition pre-eclampsia.
These were no longer visible three days later, but Samantha continued to deteriorate, with her stomach swelling and her temperature and blood pressure rising.
Like Kimberly, doctors thought Samantha was suffering from bacterial sepsis so she too was given antibiotics, which did not work.
As her organs began to shut down, she was taken to intensive care, where she stayed for four days.
A doctor suggested she be treated with antiviral medication, but they were advised by the microbiology department to continue with antibiotics instead.
Doctors called for support from a hospital in London, and surgeons took her into the operating theatre to try to stabilise her, but she died on July 4.
"They told us that unfortunately they couldn't save her - that she'd gone, passed away," her mum, Nicola Foster, told the BBC.
The post-mortem investigation found Samantha had died from multiple-organ failure following a "disseminated herpes simplex type 1 infection".
Herpes is generally passed on by skin-to-skin contact, and almost 70% of adults have one of its two strains by the time they are 25.
Some people will develop cold sores or genital herpes, but about two-thirds will have no, or mild, symptoms.
Analysis of medical records revealed neither Kimberly or Samantha had previously had herpes, so would not have built up any natural protection against the virus.
Women in the late stages of pregnancy also have less protection from their immune system.
Investigation carried out behind closed doors
More than a year after the women died, their families each received a letter from the coroner, Katrina Hepburn, saying there would be no inquests into their deaths.
The letters acknowledged there had been a similar case but said there was "no connection" between the two deaths.
They also set out the investigating pathologist's belief that the women had been infected with herpes "prior to hospital admission".
But BBC journalists who have been investigating the East Kent Hospitals Trust's maternity services since 2019 turned their attention to the deaths of Kimberly and Samantha in the spring of this year.
While reviewing documents sent to the families, they found Public Health England (PHE) had looked into how the women could have come into contact with the herpes viruses.
Kimberly's family requested PHE gave them access to that investigation, and were sent redacted emails sent between staff at PHE, East Kent Hospitals Trust, other NHS bodies and a private laboratory called Micropathology.
The emails showed PHE's investigation continued even after the coroner told the families no inquests would be taking place.
The emails also revealed a significant link between the two deaths: that the same surgeon and midwife had taken part in both Kimberly's and Samantha's C-sections.
Micropathology was asked to examine the two viruses the women had been infected with, to see if they were genetically identical and could have come from the same place.
The emails show the parts of the virus that were tested were identical.
In one email, someone working for Micropathology said both cases "look like surgical contamination".
In another email, a Micropathology worker says "it seems the most likely explanation [is] that these strains are probably the same… which also adds weight to the idea that these two women were infected with the same virus."
The laboratory asked East Kent Hospitals Trust to provide a mouth or lesion swab from "the suspect surgeon in O&G (obstetrics and gynaecology)", but this was not provided.
In a statement, the Trust says the surgeon underwent a verbal occupational health check, where he said he had no history of herpes infection and had no hand lesions, although he was not tested for the virus at the time of the operations.
KentOnline understands the surgeon no longer works for the Trust.
Expert's concern
Sexual health consultant Peter Greenhouse - who has 30 years experience in the field, and a particular interest in the herpes viruses - reviewed the cases and uncovered documents for the BBC.
Contrary to the pathologist's opinion, Mr Greenhouse believes the most likely scenario is that the infection was passed on accidentally by the surgeon carrying out the C-sections.
"The only common source here, in a hospital-based scenario, would be the surgeon who performed the operations," he says.
Mr Greenhouse told the BBC it is possible the surgeon may have had a herpetic whitlow - a herpes infection on the finger, which can range from being an open wound to an easily missable, "miniscule" bump.
He added that while surgeons wear gloves during surgery, they may have split during the operations.
Mr Greenhouse said: "It's a very rare but a very biologically plausible method of transmission."
The BBC says four other experts in sexual health and virology have backed up his theory.
Families' search for answers
Kimberly and Samantha's families are calling on the coroner to open inquests into the two women's deaths.
Kimberly's mum, Yvette Sampson, says her daughter's children deserve answers.
"When they're a bit older they're going to need to know why their mummy died," she told the BBC.
In a statement, Dr Rebecca Martin, Chief Medical Officer for East Kent Hospitals, said: “Our deepest sympathies are with the families and friends of Kimberly and Samantha.
“East Kent Hospitals sought specialist support from Public Health England (PHE) following the tragic deaths in 2018.
"The investigations led by the Trust and the Healthcare Safety Investigation Branch took advice from a number of experts and concluded that it was not possible to identify the source of either infection.
“The surgeon who performed both caesarean sections did not have any hand lesions that could have caused infection, or any history of the virus.
“Kimberly and Samantha’s treatment was based on the different symptoms showed during their illness. Our thoughts are with their families and we will do all we can to answer their concerns.”
The BBC says Peter Greenhouse is now carrying out further research into the deaths,in the hope guidelines will be changed so new mothers with similar symptoms are tested for herpes as a matter of course.
"It is the only constructive outcome that one could hope for, after such a tragic scenario," he said.