16 July 2020
A national learning report has found failures to follow national guidelines to prevent group B Strep infections in babies. The report was compiled by the Healthcare Safety Investigation Branch (HSIB) after identifying the risks associated with group B Strep from maternity investigations they carried out across England.
Their report found common themes across their investigations, including that:
- Mothers were not always provided with information on group B Strep as recommended by the Royal College of Obstetricians & Gynaecologists (RCOG), which sometimes limited the ability of health professionals to make decisions relating to the use of antibiotics during labour and the timely attendance of pregnant women to hospital.
- Mothers whose newborn babies were at raised risk of developing GBS infection were inappropriately being encouraged to stay at home for as long as possible because information was not being shared between clinicians, the right questions were not being asked by the call receiver or problems with the documentation of a mother’s GBS status.
- Positive GBS test results were not communicated to the mother or noted clearly in her records and, as a result, the recommended care and antibiotic treatment in labour were not given.
- The identification and escalation of care for babies who show signs of GBS infection after birth was missed, resulting in severe brain injury and death for some of the affected babies.
HSIB has recommended that Trusts providing maternity care should consider the report’s finding, and make changes to their local systems to ensure that mothers and babies receive care in line with national guidance.
We welcome the publication of this report, which reflects much of what families tell us on a daily basis. We know that:
• the RCOG’s 2017 group B strep guidelines have not been fully implemented
• health professionals are not fully aware of the current guidelines on group B strep
• health professionals need to be better at listening to new and expectant parents
Some of these tragedies may have been prevented had, for example, all expectant women been routinely provided with the information leaflet co-written by the RCOG and GBSS and if our ‘GBS Alert’ stickers were routinely used on the hand-held notes for all women known to be at higher risk of their newborn baby developing GBS infection.
Trusts must implement the learning from these tragedies throughout their hospitals and with their staff – until that happens, avoidable group B strep infections will continue to cause untold and preventable heartbreak to families.Jane Plumb MBE, Chief Executive Group B Strep Support
The proportion of neonatal deaths and intrapartum stillbirths where GBS contributed to the outcome, compared to other areas examined in HSIB investigations, led us to identify GBS as a risk that needed to be explored further.
The recommendations we have made are being followed up at a Trust level via the individual reports. We have published this national learning report as a crucial part of HSIB’s role is to ensure that learning is seen at a national level. It helps trusts across the country to examine their own processes, make changes to ensure the safety of mothers and babies in their care and prevent devastating outcomes for families.
As our maternity investigations rapidly progress, we will keep the theme of GBS under review and consider a future national investigation to explore the issues further.Dr Louise Page, Clinical Advisor in the Maternity Team at HSIB
This useful report highlights the need for improved training of health care professionals in the procedures necessary to reduce the threat of early onset GBS disease of the newbornProf Philip Steer, Chair of Group B Strep Support’s expert Medical Advisory Panel
Trusts must implement the learning from these tragedies throughout their hospitals and with their staff – until that happens, preventable group B strep infections will continue to cause untold heartbreak to families.
— Jane Plumb MBE, GBSS Chief Executive