Baby L - Non-inquest findings
Deceased
Baby L
Demographics
<1y, female
Date of death
2016-03-07
Finding date
2017-06-09
Cause of death
Group B Streptococcus meningitis and sepsis
AI-generated summary
An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm), and neonatal fever (39.5°C at birth). Despite these signs suggestive of chorioamnionitis, a paediatrician was not notified at birth. The baby appeared well post-delivery and was discharged home on day 3. She deteriorated at day 13 with feeding changes and irritability, presenting to hospital septic. Late-onset GBS cannot be prevented by intrapartum antibiotics. However, the coroner identified suboptimal care: the baby should have been assessed by a paediatrician at birth given maternal fever and neonatal fever, departing from Queensland guidelines. The hospital implemented significant system improvements including mandatory paediatric review within 24 hours, escalation protocols for febrile neonates, and enhanced documentation processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Late-onset GBS infection acquired after birth
- Failure to escalate febrile neonate for immediate paediatric review at birth despite maternal fever and neonatal fever
- Lack of standardised protocols for management of febrile neonates at birth
- Disjointed escalation and handover processes between nursing and medical teams
- Absence of documented paediatrician notification of maternal fever and neonatal fever at birth
- Missing neonatal feeding and observation chart limiting documentation of clinical picture
- Suboptimal assessment despite signs suggestive of chorioamnionitis (maternal fever, foetal tachycardia, neonatal fever)
Coroner's recommendations
- Develop standardised system of assessment, escalation and management of variances from normal care requiring assessment and appropriate documentation
- Implement electronic CTG partogram system with trigger alerts for maternal temperature and foetal tachycardia
- Introduce Medical Early Warning Trigger System (MEWTS) documentation for all obstetric patients
- Develop standardised GBS assessment and management system with requirements for antenatal screening on all pregnant women
- Implement requirement for all neonates to be examined by accredited paediatrician within first 24 hours of life
- Establish policy requiring babies with fever at birth, respiratory distress, or hypoglycaemia to be referred for immediate paediatrician review with contemporaneous documentation
- Implement standardised neonatal escalation tool and process for escalation of unwell babies for paediatric review
- Include neonates on Medical Emergency Team (MET) criteria list
- Review clinical handover model using SHARED framework for midwifery staff with face-to-face bedside handover for high-risk cases
- Implement Early Warning System tool in maternity services
- Develop separate neonatal feeding and observation chart with clinical escalation triggers
- Provide parent education on early signs of neonatal infection using standardised scoring systems such as Baby Check
- Ensure timely escalation of concerns to relevant Visiting Medical Practitioners
- Develop take-home booklet with feeding guidelines and log for parents to continue documenting feeding and baby output
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