Baby M

Contributing factors

• Group B Streptococcal sepsis extensively present
• Traumatic head injury from fall in corridor
• Inadequate prenatal care and risk stratification
• Failure to advise mother to attend hospital when labour detected
• Delayed induction of labour (14 days post-due date)
• Non-functional resuscitation table due to missing compatible connector
• Lack of daily equipment maintenance and checking
• Failure to administer prescribed antibiotics
• No use of available Ambu bag during first 4 minutes post-birth
• Precipitous labour due to late presentation leading to rushed birthing process
• Inaccurate due date assessment due to late pregnancy confirmation

Coroner's recommendations

1. Resuscitation tables must never use adapters and only proprietary brand resuscitation masks should be used on that brand's resuscitation table
2. A bassinet and trolley must be available in each birthing suite, and babies should only be transported using a bassinet and trolley, not carried in blankets
3. Expectant mothers should be informed about the incidence and risks of Group B Streptococcal infection and encouraged to have screening conducted if they choose
4. Wider education about this incident should occur across the health system to prevent similar circumstances
5. Staff members involved should receive, read, and understand the omissions that occurred in this death to prevent repetition
6. Hospital should clarify why some Root Cause Analysis recommendations had delayed implementation
7. Ensure expectant mothers are advised of GBS risks and encouraged to be tested if they wish, so appropriate antibiotic prophylaxis can be given if positive
8. Strengthen compliance with daily checking of resuscitation equipment
9. Improve risk stratification in prenatal care, particularly for post-date pregnancies and those with prior complications