Tragic baby deaths ‘may have been prevented’
A number of baby deaths may have been prevented if NHS maternity units all adhered to simple guidance on a common infection among pregnant women, a charity has warned.
Simple steps such as providing expectant women with information leaflets on Group B Strep (GBS), or putting warning stickers on a woman’s medical notes may prevent baby deaths and stillbirths due to the infection, according to the charity Group B Strep Support.
It comes after an investigation by the Healthcare Safety Investigation Branch (HSIB) highlighted disparities over guidance for medics and patients on the infection.
GBS is a common infection carried in the gut of up to 40% of the population where it causes no problems. But when found in a mother’s vagina it can be dangerous for babies during labour and immediately after birth.
Giving antibiotics to the mother during labour reduces the incidence of GBS infection passing on to the baby – which can lead to stillbirths, deaths in the first week of life or severe brain injury.
The new HSIB report details how an expectant mother tested positive for GBS, but she was not sent a letter confirming the infection, and telling her that she would need antibiotics in labour, until she was discharged from hospital where her baby had died.
There is guidance for maternity units for the care of women found to have, or suspected to have GBS, but the new HSIB report found that pregnant women are not always supplied with information about the infection – which can limit their ability to make decisions about the use of antibiotics in labour and when to get to hospital.
In addition some women were advised to stay at home for as long as possible before attending labour wards – which may have hampered their ability to get antibiotics in a timely fashion.
Meanwhile, positive infections are not always clearly communicated to women or reported in their medical files prominently, which might mean that antibiotic care is not offered, it added.
The report also found that some local guidelines are at odds with national guidance.
Opportunities may have been missed to spot that newborn babies were unwell – a newborn early warning score might have prompted staff to recognise unwell babies sooner, the authors said.
Commenting on the report, Jane Plumb, chief executive of the charity Group B Strep Support, said: “Some of these tragedies may have been prevented if, for example, all expectant women were routinely provided with the information leaflet 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.”
Dr Louise Page, clinical adviser in the Maternity Team at HSIB said: “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.”