Coroner's Finding: KISON Trinity Isabel

Contributing factors

• failure to administer prophylactic intrapartum antibiotics to mother despite preterm rupture of membranes
• failure to recognise and communicate significance of positive streptococcus pneumoniae in maternal high vaginal swab
• failure to administer antibiotics to neonate despite multiple clinical indications
• attribution of respiratory distress to hyaline membrane disease rather than considering early onset sepsis
• reliance on early FBE (taken 1 hour post-delivery) as reassurance without repeat testing
• failure to escalate clinical deterioration observed from 7pm onwards
• communication breakdown between obstetric and neonatal teams
• failure to appreciate significance of 8pm chest X-ray showing consolidation consistent with pneumonia
• delayed recognition that mother had received no intrapartum antibiotics
• inadequate understanding by clinicians of guidelines regarding organisms other than GBS

Coroner's recommendations

1. Multi-disciplinary review of sepsis prevention guidelines to define symptoms of sepsis, criteria for repeating FBE, and emphasise importance of administering antibiotics in preterm delivery even when time to delivery is short
2. Develop standardised policy for nurses to escalate concerns to consultant
3. Implement structured and standardised handover between obstetric and neonatal staff encompassing doctor-to-doctor/nurse practitioner and nurse-to-nurse handover
4. Microbiology laboratory to verbally notify streptococcus pneumoniae and other significant HVS organisms to requesting clinician with clinical significance comment
5. Communication between microbiology laboratory to extend to both obstetric and neonatal departments, not only obstetricians
6. Disseminate these findings to all antenatal and neonatal clinical staff at public hospitals
7. Ensure revised guidelines emphasise need for practitioners to be certain baby's symptoms are not due to early onset sepsis before deciding not to administer antibiotics
8. Emphasise importance of considering risk factors such as prematurity alongside clinical presentation
9. Deliver education to junior practitioners concerning potential effects of neonatal pathogens other than Group B Streptococcus
10. Remind clinicians of importance of handovers and need for full information to be imparted during handovers
11. Implement FMC protocol of routine antibiotic administration for unresolved respiratory distress after 4 hours with consideration of preterm risk factors