HSIB Learning Report - babies seriously injured from maternity and neonatal errors in GBS (group B strep) care

The Healthcare Safety Investigation Branch or HSIB have published a national learning report from their investigations of maternity and neonatal errors in GBS (group B strep) care resulting in serious birth and neonatal injury to babies.

The national learning report, Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection, identifies common mistakes in the care of pregnant women with GBS and their seriously injured babies, so that lessons may be learned to prevent further harm.

What is HSIB?

The Healthcare Safety Investigation Branch, or HSIB, investigates patient safety concerns in NHS care in England. From 1 April 2018, HSIB has been responsible for all NHS maternity safety investigations which meet the RCOG’s Each Baby Counts criteria. These include stillbirths, neonatal (newborn) deaths and full term babies who suffered severe brain injury at birth.

HSIB’s investigations identify factors that may have exposed individual patients to harm and make recommendations to improve healthcare systems and processes, to reduce risk and improve safety. HSIB’s national learning reports identify lessons from these investigations which, if learned, should improve patient safety. The latest national learning report focusses on the maternity and neonatal care of mothers and babies with group B streptococcus (GBS). 

What is Group B Strep?

Group B streptococcus (GBS or group B strep) is a common bacterium which is carried in the intestines of 20 to 40% of the population. 20% of women carry GBS in their vagina. In most cases they are unaware that they have GBS and it causes them no harm, but during pregnancy, labour and childbirth and in the early weeks of life it can be dangerous for their baby. When the baby develops GBS infection within the first week after birth this is known as early onset GBS and probably arose from infection in the uterus in pregnancy or during their delivery through the birth canal. Babies can also develop late onset GBS infection in the first few weeks and months of life but this is more likely to be the result of exposure to GBS from other sources. 

GBS is the most common cause of severe infection in the first week of a baby’s life. Where a pregnant woman is known to carry GBS, her baby’s risk of early onset GBS is reduced by giving the mother antibiotics during labour and birth.

Currently the UK does not recommend routine screening for all pregnant women to check if they are carrying GBS, or testing after spontaneous rupture of membranes (waters breaking) or the onset of labour. Justification for refusing to offer routine screening or testing often refers to the fact that many mothers with GBS give birth safely without their baby developing GBS infection, that screening isn’t always accurate and can’t predict who will become infected, and concerns about giving antibiotics to large numbers of women who don’t need it. Other reasons include the risk of allergy to penicillin, concerns about the long-term effects of antibiotics on a newborn baby who might not need them, and that if intravenous treatment is needed this limits the mother’s choice of birth place to a hospital setting. 

Some women choose to have GBS screening carried out privately. Then if they have a positive GBS result they are entitled to antibiotic treatment during labour and childbirth. According to HSIB, at least 60 other countries use some form of GBS screening and antibiotic treatment in pregnancy to prevent neonatal GBS. Universal GBS screening in labour has been recommended in the USA since 2002, and in Europe since 2015. A large study is due to start in the UK in 2020 to evaluate the effect of screening mothers during pregnancy or testing for GBS at the onset of labour. Research trials are also being carried out on a potential antenatal GBS vaccine.

HSIB’s learning report finds common GBS (group B strep) treatment errors in maternity and neonatal care

HSIB found that in 13% of all their completed maternity safety investigations the mother or baby had GBS. For 15 of those babies, GBS infection contributed to their outcome. Six were stillborn, six died in the first week of life, and three babies suffered severe brain injury. HSIB’s investigations found repeated errors in the maternity and neonatal care of mothers and babies with GBS infection before, during and after birth. 

Errors during pregnancy (antenatal) included:

• Failing to comply with RCOG guidance that all mothers (not just those with GBS) should receive information about GBS. 
• Mothers known to be carrying GBS were given inadequate information about their care plan in labour, including when to attend the maternity unit. 
• Failing to comply with national guidance on when to recommend or give antibiotics in pregnancy. GBS infection in the mother’s urine needs immediate antibiotic treatment. In one case, failure to give antibiotics after a GBS positive urine test led to infection in the placenta and membranes surrounding the baby (chorioamnionitis).

Errors during labour and delivery (intrapartum) included:

• Failing to give antibiotics within one hour of the onset of labour, or admission in labour, and then continuing throughout labour, to mothers at risk of early onset GBS infection of the baby. Risk factors include where the mother:
  • is in premature labour;
  • has had a previous baby with GBS infection;
  • carries GBS, or has GBS in their urine or has GBS infection in their current pregnancy;
  • has a raised temperature or signs of infection during labour.
• Delay or failure to give antibiotics in labour to mothers with group B strep (GBS) was very common and often linked to lack of available staff at the time when antibiotics should have been started.
• Mothers in early labour with GBS were often advised to stay at home until they were in established labour, delaying their antibiotics. Decisions about when to admit a mother in labour were sometimes affected by maternity unit workloads. 
• Inadequate risk assessments and incorrect advice given to GBS positive mothers whilst at home in early labour.
• Inadequate documenting of information (such as the mother’s higher risk status from her GBS infection) meant that key information was not available to other staff members who saw her later. 
• Doctors failed to access computerised test results which showed that a mother in labour had GBS and needed antibiotics.
• Failing to communicate positive GBS test results with the mother.
• Failing to note positive GBS test results in the mother’s records.
• Failing to give antibiotics immediately and offer early induction of labour to GBS positive women whose waters broke before starting labour. 
• Out-of-date local GBS guidance resulting in staff failing to provide correct information and antibiotics to mothers with GBS. 
• Lack of staff availability often led to delays in essential treatment. This included obstetricians or anaesthetists being busy with other patients, resulting in delays in reviewing the mother’s condition, prescribing or giving antibiotics, or siting a cannula for intravenous antibiotics, or epidurals before starting syntocinon to speed up labour. 

Postnatal and neonatal errors in GBS care included:

• Missing information in the neonatal records led to delays in diagnosis and treatment of babies at risk of GBS infection.
• Delayed recognition or escalation of care for babies showing signs of GBS infection after birth.
• Failing to recognise signs of deterioration in the baby’s condition, including reluctance to feed. 
• Delay or failure to give antibiotics urgently to babies with suspected neonatal GBS infection.
• Communication failure within the multidisciplinary team.
• Lack of advice to parents about recognising signs of the baby’s deterioration at home and seeking medical help. 

One or more of these common errors contributed to the avoidable death or severe brain injury of 15 babies in HSIB’s small sample of cases. In addition to specific recommendations given in each individual case, HSIB recommend that maternity care providers across the NHS consider the findings of the learning report and ensure that changes are made to ensure that the lessons are learned. 

Meanwhile, NHS Resolution have added GBS as a new code to its claims management system to help them work with NHS trusts identify claims, trends and learning themes for improvement from these devastating but avoidable injuries.

Boyes Turner’s experienced GBS negligence solicitors help brain injured babies claim compensation

Boyes Turner’s experienced brain injury lawyers have helped countless families recover maximum compensation for their child’s cerebral palsy and neurological disability after mistakes in maternity and neonatal care. We understand neonatal GBS, meningitis and brain injury and the devastating impact these injuries have on the individual and their family. Our focussed approach ensures that as soon as liability is established our clients have access to interim payments to provide help with care, adapted accommodation, therapies, specialist equipment, special educational support, whilst we work with the family and our experts towards a settlement which provides for the child’s lifelong needs. 

If you are caring for a child with severe disability arising from negligent maternity or neonatal care and would like to find out more about making a claim, contact us by email on cerebralpalsy@boyesturner.com.