Elsie Plumb
PFD Report
Historic (No Identified Response)
Ref: 2014-0455
Coroner's Concerns (AI summary)
The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
View full coroner's concerns
_ The consultant obstetrician and gynaecologist gave evidence and indicated that changes had taken place at the hospital to clarify guidance in relation to administering antibiotics to the mother, and when this should be done He indicated that the Royal College of Obstetricians Gynaecologists Green-top Guideline No. 36 titled "The Prevention of Early-onset Neonatal Group B Streptococcal Disease" at paragraph 5.4 on page 4 could be more clearly written_ He stated that the sentence currently reads "If GBS colonisation was identified earlier in the pregnancy (by a swab taken for other reasons) immediate induction of labour and IAP should be offered" 14"h and
He suggests that this sentence would be clearer if it were written as follows: immediate induction should be offered. IAP should also be offered, whether or not immediate induction is performed.
He suggests that this sentence would be clearer if it were written as follows: immediate induction should be offered. IAP should also be offered, whether or not immediate induction is performed.
Sent To
- Royal College of Obstetricians and Gynaecologists
Response Status
Linked responses
0 of 1
56-Day Deadline
16 Dec 2014
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 1st May 2014 commenced an investigation into the death of Elsie Sue PLUMB, aged Ihour: The investigation concluded at the end of the inquest on October 2014. The conclusion of the inquest was Natural causes_ Elsie Plumb died at 08.30 hours on 15"h April 2014 at the Royal United hospital, Combe Park, Bath, due to sepsis_ The medical cause of death was recorded as 1a Group B Streptococcal Septicaemia
Circumstances of the Death
Elsie Plumb was born full term Her mother during the ante-natal period was confirmed as positive for Group B beta haemolytic streptococcus and it was recorded in the notes that she would therefore need antibiotic cover in labour. This did not happen due to the nature of the labour and delivery. Sadly Elsie Plumb died within an hour of delivery due to early onset of early neonatal sepsis due to the Group B streptococcal infection:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Apply best offer principle equally in GLOS
Post Office Horizon Inquiry
Outdated Operational Guidance
Post Office to engage in negotiations during HSSA appeal period
Post Office Horizon Inquiry
Outdated Operational Guidance
Set deadline for HSS claims with guidance on late applications
Post Office Horizon Inquiry
Outdated Operational Guidance
Clarify whether HCRS and OCS assessment processes differ
Post Office Horizon Inquiry
Outdated Operational Guidance
Establish standing public body to administer future redress schemes
Post Office Horizon Inquiry
Outdated Operational Guidance
Devise redress process for affected family members
Post Office Horizon Inquiry
Outdated Operational Guidance
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.