Posted by Kerstin Kubiak, Partner
NHS maternity care for mothers carrying Group B Strep must improve
It was with great dismay that I read today of an inquest, which heard evidence relating to the tragic death of baby Rocco, who died at the James Cook University Hospital in Middlesbrough in June 2017. Rocco’s mother was a known carrier of group B Streptococcus (GBS). However, despite this being made clear in her medical records, she was not admitted to hospital for antibiotic therapy following the rupture of her membranes.
The charity Group B Strep Support has been campaigning for years for much improved training and awareness amongst NHS maternity staff to help with the diagnosis and management of maternal group B Strep carriage. Sadly, despite these efforts there continue to be cases where significant errors are made which result in the worst possible outcome for a family: the death of their baby.
An inquest has heard how a newborn baby tragically died in June 2017 at the James Cook University Hospital in Middlesbrough; the baby’s mother attended hospital the day before the birth reporting ruptured membranes and highlighted to staff that she was noted to carry GBS. Despite this, the midwife who assessed her did not admit her to hospital for prophylactic antibiotic therapy and instead discharged her home.
As a result of this significant delay in the administration of antibiotics the mother’s amniotic fluid became infected with GBS leading to the unborn infant developing pneumonia. Following a very difficult birth baby Rocco was delivered in a very poor condition and died at only 90 minutes of age.
Tragically the inquest concluded that Rocco’s death would have been avoided with the timely and appropriate administration of antibiotics. The coroner, Claire Bailey, noted the full admission of the midwife that a serious error had been made, and the Trust informed the coroner that changes had since been made at the Trust. For example, instituting a sticker system (similar to those provided by Group B Strep Support) to ensure patients known to carry GBS are appropriately treated and that their protocol (which had been in place at the time but was not followed) be reiterated to guide staff.
Although human error was at fault in this case there were clearly insufficient systems and safe-guards in place to guard against the failures of a busy midwife and to ensure that there was another layer to “red flag” the care needed by women who carry GBS. If this had been in force then baby Rocco’s death is likely to have been avoided.
How Group B Strep Support is highlighting this problem
The charity Group B Strep Support recently produced a report following a survey of 6 of their legal panel members (us included). When they analysed the reported cases they found: “The most common reason for a breach was a negligent failure to administer antibiotics.” They noted one of the two main reasons for such a failure was: “Failure to give antibiotics as timely preventative action – typically where a mother was known to carry GBS, and preventative antibiotics were not given.”
These scenarios are simply unacceptable, and as shown by this inquest, result in devastation for a family who have lost their child.
No parents should have to face such an ordeal when the treatment available is uncomplicated and inexpensive; not only should NHS staff have improved training and awareness around GBS infection, but hospital trusts must also ensure there are improved safeguards for patients.
For more information on how we can help to investigate treatment received in relation to group B Strep please see our information page here.
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