Babies dying from treatable infection, watchdog reports
Babies are at risk of dying from common treatable infections because NHS staff on maternity wards are not following national guidance and are short-staffed and overworked, an investigation has revealed.
The Healthcare Safety Investigation Branch (HSIB), a national safety watchdog, warned that NHS staff on maternity wards face sometimes conflicting advice on treating women who are positive for a group B streptococcus (GBS) infection. They are also making errors in women’s care because of the pressure of work and a lack of staff, with antibiotics not being administered when they should be.
HSIB’s specialist investigators examined 39 safety incidents in which GSB had been identified, and found
that the infection had contributed to six baby deaths, six stillbirths and three cases of babies being left with severe brain damage.
In its report, the watchdog warned that the problems on maternity wards meant that even in cases where mothers were known to be positive for GBS infection, this wasn’t shared with the mother or noted in the record, resulting in the standard care and antibiotics not being provided.
It added: “The identification and escalation of care for babies who show signs of GBS infection after birth was missed. This has resulted in severe brain injury and death for some of the affected babies.”
HSIB said there were inconsistencies between national guidance produced by the Royal College of Obstetricians and Gynaecologists in 2017 and local rules that aimed to keep women out of hospital until they are in established labour. The report said this was an example of a wider issue in healthcare of “work as prescribed” versus the reality on the ground for staff, or “work as done”.
A lack of staff was noted in four incidents, with staff attending other mothers or carrying out other tasks at the time when antibiotics needed to be started. For nine women in the 39 incidents that were examined, antibiotics for GBS were required but not given. Reasons included poor documentation and, in one example, difficulty inserting a cannula.
HSIB said: “When such clinical difficulties occur, an anaesthetist may be asked to attempt the procedure. On this occasion, the anaesthetist was busy in the operating theatre and unable to attend.”
Some GBS-positive mothers were being told to wait too long at home after labour had started despite guidance saying they should attend earlier to receive antibiotics.
In its report, HSIB said it found cases where services were “encouraging mothers to stay at home for as long as possible. In some cases, this was due to information not being shared between clinicians, the right questions not being asked by the call receiver, or problems with the documentation of a mother’s GBS status.”
In one case, an ambulance was called to the home of a family after a baby was partially born “several hours” after the family made two calls to the maternity unit. The calls were answered by separate staff.
HSIB said: “A full assessment of the mother was not undertaken as recommended in local guidance. There was limited documentation recorded during the telephone conversations. Sadly, this baby died and while GBS did not contribute directly to the death, earlier admission to hospital may have increased the baby’s chances of survival.”
GBS is a naturally occurring bacteria that is thought to be carried by about 20 per cent of women in their vagina, posing a risk to the baby. Mothers are not automatically screened for GBS, but where a positive infection is detected, they should be given antibiotics during labour.
GBS is the most common cause of severe infection in babies within the first week of life. It has been found in 13 per cent of more than 290 maternity investigations carried out by HSIB since 2018.
The watchdog, which uses air-accident investigation approaches to safety incidents in order to identify systemic issues, said: “Investigations found problems where positive tests for GBS were not communicated to the mother or noted clearly in the case records. As a result, the recommended care and antibiotic treatment in labour was not given.”
This happened in 22 cases out of the 39 that were examined.
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.”
Jane Plumb, chief executive of the charity Group B Strep Support, added that national guidelines from 2017 have not been fully implemented and some health professionals are unaware of them.
She 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.”
A major trial to explore whether routine GBS screening for pregnant women could reduce infections and deaths is due to start this year, involving 80 hospitals in the UK and with 320,000 women expected to take part.
NHS England was approached for comment but referred the query to the Department of Health and Social Care.