Frimley Health NHS Foundation Trust

5. Miss B complains about the care and treatment she received from the Trust in April and May 2025. She says the Trust:

• did not promptly identify a positive GAS test and missed several further opportunities to commence antibiotic treatment prior to going into labour in May 2025 • did not inform her of the risks presented by GAS and did not offer adequate guidance and support following her positive diagnosis • did not adequately respond to her complaint.

6. Miss B says the delays in her care meant she went into preterm labour and her newly born baby also became severely unwell with meningitis. She says she had to be isolated with her newborn and was told there was a risk they would need to go to intensive care. She says she was unable to see her other child for five days. She says the experience has affected her mental health and affected her trust in medical professionals concerning her baby’s care. She says she has lost trust in the system and the negative experience means she cannot consider having more children in the future.

7. Miss B is seeking an apology, service improvements and financial remedy.

8. Miss B was pregnant with her second baby in April 2025. At the end of April, she attended maternity triage with abdominal pain and back pain. She underwent an actim partus test (a test to check the risk of preterm delivery) and a high vaginal swab (HVS) test (a procedure where a sample is taken to check for infection) and kept in overnight for observation. She was discharged the following day and the sample was booked into the laboratory for testing.

9. Miss B did not hear back about the results of the test for a week. In early May, she reviewed the NHS app and saw the results showed as positive for group A streptococcus. She contacted maternity triage on the same day, and again the following day, seeking clarification about whether she needed antibiotics. A day later, maternity triage told her she was on a doctor’s list for review.

10. Two days after raising the issue, a gynaecologist called Miss B and explained the results of the positive swab result. The doctor prescribed a week’s course of clindamycin antibiotics (used to treat bacterial infections) and gave safety netting advice. Miss B’s relative collected the antibiotics that evening.

11. The following day, Miss B went into preterm labour at 36 weeks pregnant and was administered IV antibiotics. A day later, she gave birth to her baby, C.

12. Shortly after the birth, the Trust told Miss B that, given her positive GAS test, she would need to be isolated and undergo treatment due to the risks GAS posed to postnatal women. It told her any resulting infection could be life threatening and may require admission to intensive care. It said she would need to be isolated from other pregnant and postnatal women and that the Health Security Agency would be informed. The Trust gave her broad spectrum antibiotics and said it would carry out an investigation concerning the delay in identifying her positive test and the delay in action once it was identified.

13. Miss B spent several days in isolation and the Trust’s Transitional Care Unit (TCU). Two days after birth, C was moved to the neonatal ward with suspected meningitis. Miss B was discharged with oral antibiotics so she could be with her baby. Miss B believes her Group A streptococcus infection may have contributed to her baby’s meningitis diagnosis.

14. Miss B was discharged home with C later that month.

The Trust did not promptly identify Miss B’s positive GAS test and missed opportunities to commence antibiotic treatment sooner

18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Miss B has claimed.

19. Miss B says the Trust did not identify her positive GAS test promptly and missed opportunities to treat her with antibiotics sooner. She feels this error may have contributed to her going into pre-term labour and to her baby, C, being diagnosed with meningitis shortly after birth.

20. In its final response, the Trust acknowledged it did not identify Miss B’s positive GAS result promptly. It apologised and said the delay had been caused by an administrative issue at the laboratory, which meant the result was not visible to doctors. It also acknowledged there had been a delay in a doctor reviewing the result once available and made a further apology. It said the delays may have contributed to Miss B going into preterm labour and that C’s meningitis diagnosis was unconnected to Miss B’s positive test for GAS.

21. GMC ‘Good medical practice’ says clinicians should promptly provide suitable advice, investigation or treatment where necessary.

22. NICE NG195 says babies suspected of having sepsis should be given antibiotic treatment for seven days.

23. Our obstetrics adviser said the Trust had not acted in line with GMC guidance in its review of Miss B’s swab result, as acknowledged in its response to Miss B’s complaint. They said Miss B’s test result showed she was carrying GAS (colonisation) but did not have an active infection. They explained that recent research suggests 11.1% of pregnant women between 35 and 37 weeks pregnant were carrying GAS without symptoms. They said many women carry GAS during pregnancy and never have a swab test so do not become aware, and do not subsequently develop complications. They said antibiotic treatment is given pre-emptively in response to a positive test for GAS colonisation, to reduce the chance of the colonisation causing an active infection in the mother or baby.

24. They said it was not possible to know whether Miss B’s GAS colonisation contributed to her going into preterm labour. They also said it is not possible to know whether starting antibiotics sooner would have significantly reduced that risk.

25. Our neonatologist adviser said the Trust treated C appropriately and in line with NICE NG195 guidance following assessment of her clinical symptoms, which were suggestive of sepsis. They said they underwent several appropriate investigations, including blood and cerebrospinal fluid (CSF) cultures, which did not show any evidence of GAS infection. They said C’s CSF culture showed the presence of enterovirus, which suggests C’s symptoms were caused by enterovirus meningitis, rather than GAS.

26. Our neonatologist adviser said there is no known association between GAS colonisation in the mother and enterovirus meningitis in a newborn. They said it is therefore very unlikely that Miss B’s GAS colonisation contributed to C’s subsequent illness.

27. Our ‘NHS complaint standards’ say organisations should give fair and open answers, be accountable for their actions and give meaningful and sincere apologies. They say organisations should take forward relevant learning and improvements following a complaint.

28. In its final response, the Trust apologised to Miss B for the delay in reviewing her swab and in prescribing antibiotics. It detailed improvements it has made to its IT system and laboratory process to ensure these delays will not be repeated. It also apologised for Miss B’s unsettling experience of going into preterm labour unexpectedly.

29. Our ‘Severity of Injustice’ scale defines a level one injustice as when a person has experienced frustration, annoyance or worry as a result of a one-off incidence of service failure, where the effect is of short duration and there are no other adverse effects or ongoing wider impacts. We usually consider an apology to be appropriate remedy in these cases. We consider this part of Miss B’s complaint falls at level one on our scale.

30. We understand Miss B’s concern that the Trust did not identify her GAS result promptly and missed opportunities to start her antibiotic treatment sooner. We appreciate her worry that these issues may have contributed to her going into preterm labour and to C becoming ill. We understand how distressing this period of time was for her.

31. Having reviewed the evidence, we consider that the Trust did not treat Miss B in line with guidance. However, we cannot link these indicated failings with the impact Miss B has claimed. We will therefore not be looking at this part of the complaint further.

The Trust did not inform Miss B of the risks presented by GAS and did not offer adequate guidance and support

32. Having looked this part of the complaint, we have decided the Trust has already done enough to put right the impact on Miss B.

33. In its final response, the Trust acknowledged that the risks of GAS were not fully explained to Miss B over the telephone. It also acknowledged that Miss B was not informed of the risks of GAS and the infection control measures required when she was admitted to hospital. It said this was not an acceptable standard of care and apologised.

34. GMC ‘good medical practice’ says clinicians must give patients the information they want or need in a way they can understand. This includes information about their condition, likely progression, options for management and treatment and any uncertainties for each available option.

35. Our obstetrics adviser said the Trust had not acted in line with GMC guidance in its communication with Miss B following her GAS test result, as acknowledged in the Trust’s final response. They said Miss B’s medical records for her telephone conversation with a doctor following her positive test result suggest the swab results were explained and safety netting advice was given, but there is no additional detail on what this entailed. They said there would not have been a clinical impact on Miss B as a result of the Trust’s shortcomings in communication.

36. In its final response, the Trust also acknowledged that awareness of the risks of GAS, the care needed and the infection control measures necessary needed increasing among its staff and outlined some clinical education which had been planned for all staff to ensure improvements in care in the future. This is in line with our complaint standards.

37. We consider this part of Miss B’s complaint falls at level one on our scale (paragraph 29). We usually consider an apology to be appropriate remedy in these cases.

38. Having reviewed the evidence, we consider the Trust responded to this part of Miss B’s complaint in line with our complaint standards and that a financial remedy would not be appropriate. We will therefore not be looking at this part of the complaint further.

The Trust did not adequately respond to Miss B’s complaint

39. Miss B told us she felt the Trust’s response to her complaint was inadequate. She said she felt the apologies given were insufficient and that she was not confident the Trust would make the necessary improvements to prevent the issues happening again.

40. Our ‘NHS complaint standards’ say organisations should give fair and accountable responses and take responsibility where things have gone wrong. They say organisations should give meaningful, sincere apologies and transparent explanations, and should take forward relevant learning and improvements following a complaint.

41. Having reviewed the evidence, we consider the Trust responded to Miss B’s complaint in line with our complaint standards. It provided clear explanations of how and why Miss B’s care and treatment had not met the standards required and apologised for the effect this had on her and her experience. It also detailed several specific improvements it was making to its processes and education processes it had planned for its staff in response to Miss B’s complaint. We consider this is in line with our complaint standards. We will therefore not be responding to this part of the complaint further.

42. We thank Miss B for taking the time to bring her complaint to us. We understand how distressing this experience was for her and appreciate her concern that her experience is not replicated in the future. We hope this statement explains how we considered her complaint and reassures her the Trust has taken appropriate steps to improve. We wish her and her family the best for the future.

1. We have carefully considered Miss B’s complaint about the care and treatment she received from the Trust in April and May 2025.

2. Having reviewed the evidence, we consider that the Trust did not act in line with guidance when it did not promptly identify Miss B’s positive Group A Streptococcus (GAS) test and missed several opportunities to commence antibiotic treatment. GAS is a common type of bacterial infection which can cause mild to severe disease in pregnancy. We consider we cannot link these indicated failings to the claimed injustice of Miss B going into preterm labour and her baby, C, becoming ill with meningitis.

3. We also consider the Trust did not act in line with guidance when it did not inform Miss B of the risks and did not offer adequate guidance and support. Having reviewed the evidence, we consider the Trust has already done enough to put right the impact of these events on Miss B.

4. We consider the Trust responded to Miss B’s complaint in line with our complaint standards. We explain our reasoning behind these decisions in more detail below.