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Insight

HSIB report on Group B Strep a wake-up call for healthcare professionals

Mark Bowman
17/07/2020
The Healthcare Safety Investigation Branch (HSIB) has published its long-awaited report into risks associated with group B Strep following investigations conducted across England. Worryingly, the following failings were identified:

1. Mothers are not always given information about Group B Strep (GBS) as recommended by the Royal College of Obstetricians and Gynaecologists. The most recent RCOG guidelines, published in 2017, recognise that GBS is the most frequent cause of severe early onset infection in babies. The guidelines provide healthcare professionals with advice on the prevention of the disease and information to be provided to women, their partners and families.

Among its recommendations are that all pregnant women should be offered an appropriate information leaflet and be advised that the risk of maternal GBS carriage in pregnancy is 50 per cent. The HSIB report suggests this is simply not happening. . The HSIB was aware of eight cases where this had clearly not been the case.

2. Mothers whose new-born babies were at increased risk of developing GBS infection were wrongly being encouraged to stay home for as long as possible. The HSIB had itself reported on four cases where mothers were advised to stay at home even though they were GBS positive and reporting regular contractions.

3. Positive GBS test results were not being communicated to mothers or being written up clearly in their notes, meaning intrapartum antibiotic prophylaxis is not always given quickly enough, increasing the risk of significant harm to the baby. The HSIB knew of four cases where there was a delay in providing such treatment.

4. Identification and suitable provision of care for babies with symptoms of GBS after birth were being missed, resulting in either severe brain injury or death.

Following publication of the report, Jane Plumb MBE, Chief Executive of Group B Strep Support, said she welcomed publication of a report that reflects what the organisation is regularly told by families, specifically 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 new-born baby developing GBS infection," Ms Plumb said.

"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.

The birth injury specialists within the team at Fieldfisher, including myself, are very concerned by the failings outlined in the report. Basic and easily avoidable errors are still being made, with devastating consequences to mothers and their babies.

Hopefully this report will be a wake-up call for the healthcare profession and will ensure that practitioners are given proper training so they understand and recognise the relevant clinical signs, that they provide mothers with the advice and assistance they require, and that there is earlier recognition of this horrendous condition.

For more information please Mark Bowman on 020 7861 4043 or email mark.bowman@fieldfisher.com.

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