NHS Resolution publishes learning from claims: early onset Group B Streptococcal disease in neonates

NHS Resolution recently published its new patient safety report Learning from claims related to early onset Group B Streptococcal disease in neonates which identifies key themes from the analysis of 19 closed claims notified between January 2016 and March 2023.

Early onset Group B Streptococcus (EOGBS) is the leading cause of serious bacterial infection in newborns during the first few weeks of life. The report identifies key themes from the claims data, including the importance of effective communication of test results, timely administration of antibiotics and early recognition of sepsis.

Whilst this is recognised as a small cohort of patients, the analysis offers valuable learning opportunities. The key findings, which were developed with clinical experts, are set out in the context of demographics, antenatal and intrapartum stages and sepsis management. These include:

• 76% of babies showed symptoms within the first 24 hours of life.
• Only 25% of babies received antibiotics within one hour of sepsis being suspected.
• Claims are often related to the management of GBS test results rather than the initial decision to test.
• Misinterpretation of CTGs in the context of a fetus already compromised by sepsis contributed to this cohort of claims.

The report makes practical recommendations to help trusts improve their maternity and neonatal services along with highlighting the existing recommendations that are in place and available national resources that relate to the findings. Suggested improvements include improved triage systems, robust processes for tracking and communicating GBS test results and enhanced staff training in recognising signs of sepsis.

The report’s findings and recommendations align with existing national guidance from the Royal College of Obstetricians and Gynaecologists, the Health Services Safety Investigations Body, and NHS perinatal safety initiatives which aim to improve care for women, babies and families. The report also directs parents and healthcare professionals to supplementary learning material to support understanding of and response to NHS Resolution’s findings.

NHS Resolution continues to support the important wider work currently being undertaken to improve NHS maternity and neonatal care through both its thematic patient safety reviews and its expert advice to the National Maternity Taskforce, to which its Director of Patient Safety, Megan Bidder, was recently appointed.