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. Report an inaccuracy.

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
Full text
Official source Archived copy

Related cases from SA

SAhospital2023-07-28

Coroner's Finding: Searle, Bodhi Leo

0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia

Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…

obstetricsmidwiferydiagnosticcommunication
SAhospital2016-05-25

Coroner's Finding: PALTRIDGE Mellanie Joanne

25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss

A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…

obstetricsemergency medicinediagnosticdelayparacetamol
SAhome2016-01-28

Coroner's Finding: NAPIER Ebony Simone

0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father

Ebony Napier, aged 4 months, died from blunt head trauma resulting from multiple deliberate blows inflicted by her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian ch…

paediatricsradiologydiagnosticcommunicationcannabis

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.