Coronial
SAhospital

Coroner's Finding: LINNELL Sienna Jools

Deceased

Sienna Jools Linnell

Demographics

0y, female

Date of death

2006-10-17

Finding date

2009-06-24

Cause of death

Group B Streptococcus infection

AI-generated summary

A 7-hour-old neonate died from early-onset Group B Streptococcus (GBS) infection contracted during labour. The mother's GBS screening test at 35-37 weeks gestation was reported negative, and no antibiotic prophylaxis was administered during labour despite prolonged rupture of membranes (43 hours) and significant labour duration (17 hours). The coroner found the death preventable—if antibiotics had been given, the infant would likely have survived. Key issues include: reliance on a falsely negative screening result; failure to recognize that risk factors (prolonged PROM) persist despite negative screening; lack of informed consent discussion; and South Australian guidelines that failed to address false negatives. The coroner recommended amended guidelines to administer prophylactic antibiotics to GBS-negative women with prolonged PROM (≥18-24 hours), improved informed consent processes, and development of rapid intrapartum GBS testing.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

obstetricsgeneral practicemidwiferyneonatologypathology

Error types

systemcommunicationdiagnostic

Clinical conditions

group b streptococcus infectionearly onset neonatal sepsispre-labour rupture of membranesprolonged rupture of membranespneumoniabacteraemianeonatal shock

Procedures

vaginal examinationscalp electrode applicationventouse suction deliveryGBS screening test

Contributing factors

  • False negative GBS screening test result
  • Failure to recognize prolonged rupture of membranes as a risk factor despite negative screening
  • Absence of antibiotic prophylaxis during labour
  • No induction of labour despite 43-hour post-PROM period
  • Multiple internal vaginal examinations during labour increasing infection risk
  • Scalp electrode application increasing risk of ascending infection
  • South Australian Department of Health guidelines that did not recommend antibiotics for GBS-negative women with prolonged PROM
  • Lack of informed consent discussion regarding GBS risk and antibiotic options

Coroner's recommendations

  1. The South Australian Minister for Health, Department of Health, and Medical Board of South Australia should bring findings to the attention of the medical profession, specifically highlighting the incidence of false negative GBS screening results and the potential adverse consequences of relying solely on reported negative results
  2. The South Australian Department of Health should amend its guidelines on intrapartum antibiotic prophylaxis to recommend antibiotic prophylactic cover for women at term who are reportedly GBS-negative but have prolonged rupture of membranes greater than 18 hours (or 24 hours if considered more appropriate), notwithstanding the reported negativity of their test
  3. Include reference in guidelines to the incidence of false negative GBS screening test results
  4. Include reference in guidelines to suggest clinicians consider advising induction in cases of term PROM
  5. Encourage clinicians to involve women and their partners in decision-making regarding antibiotic prophylaxis and induction
  6. The South Australian Department of Health should consider whether GBS screening examinations should involve taking an anal swab in addition to a low vaginal swab
  7. The South Australian Department of Health should participate in and continue to monitor development of more accurate screening methods for GBS, particularly rapid intrapartum testing methods
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