Source · Prevention of Future Deaths
Elsie Plumb
Ref: 2014-0455
Date: 21 Oct 2014
Coroner: Maria Voisin
Area: Avon
Responses identified: 0 / 1
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The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
Date
21 Oct 2014
56-day deadline
16 Dec 2014 est.
Responses identified
0 of 1
Coroner's concerns
The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
View full coroner's concerns
_ The consultant obstetrician and gynaecologist gave evidence and indicated that changes had taken place at the hospital to clarify guidance in relation to administering antibiotics to the mother, and when this should be done He indicated that the Royal College of Obstetricians Gynaecologists Green-top Guideline No. 36 titled "The Prevention of Early-onset Neonatal Group B Streptococcal Disease" at paragraph 5.4 on page 4 could be more clearly written_ He stated that the sentence currently reads "If GBS colonisation was identified earlier in the pregnancy (by a swab taken for other reasons) immediate induction of labour and IAP should be offered" 14"h and
He suggests that this sentence would be clearer if it were written as follows: immediate induction should be offered. IAP should also be offered, whether or not immediate induction is performed.
He suggests that this sentence would be clearer if it were written as follows: immediate induction should be offered. IAP should also be offered, whether or not immediate induction is performed.
Report sections
Investigation and inquest
On 1st May 2014 commenced an investigation into the death of Elsie Sue PLUMB, aged Ihour: The investigation concluded at the end of the inquest on October 2014. The conclusion of the inquest was Natural causes_ Elsie Plumb died at 08.30 hours on 15"h April 2014 at the Royal United hospital, Combe Park, Bath, due to sepsis_ The medical cause of death was recorded as 1a Group B Streptococcal Septicaemia
Circumstances of the death
Elsie Plumb was born full term Her mother during the ante-natal period was confirmed as positive for Group B beta haemolytic streptococcus and it was recorded in the notes that she would therefore need antibiotic cover in labour. This did not happen due to the nature of the labour and delivery. Sadly Elsie Plumb died within an hour of delivery due to early onset of early neonatal sepsis due to the Group B streptococcal infection:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
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Report details
- Reference
- 2014-0455
- Date of report
- 21 October 2014
- Coroner
- Maria Voisin
- Coroner area
- Avon
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Dec 2014 (estimated).
Sent to
- Royal College of Obstetricians and Gynaecologists