Recurring concern

Failure to reliably provide antenatal information about preventable infection risks and vaccination

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First reported 16 Jul 2015•Latest report 27 Oct 2020

Definition

What this concern includes

Includes failures in antenatal systems to identify eligible pregnant women, provide clear information about preventable infection risks or recommended vaccination, assign responsibility, and audit or follow up that the information was provided.

Not included

  • Excludes failures to administer or deliver a recommended vaccination after eligibility and advice have been established; those belong to vaccination-provision concerns.
  • Excludes condition-specific diagnosis, screening, antibiotic treatment or postnatal care failures where antenatal preventive information is not the deficient control.
  • Excludes generic antenatal communication, documentation or staffing deficiencies unless they directly impair provision or assurance of preventive infection-risk or vaccination information.
  • Excludes medication-safety advice during pregnancy and other antenatal counselling unrelated to preventable infection risks or recommended vaccination.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2015–2020

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Milton Keynes University Hospital1
NHS England1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Milton Keynes

    AI-generated summary

    Reggie -Jay John PAYNE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Reggie -Jay John PAYNE was found unresponsive in his cot on 16 December 2020 and was confirmed dead at hospital after attempts at resuscitation. A Group B streptococcal infection was identified at post mortem, and the report raised concerns that Group B strep was not discussed during pregnancy and that screening and intrapartum antibiotics might have been relevant.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide pregnant women with information about GBS and its risks to newborn babies

    Wider context from the report

    “During the course of the inquest I was referred to the HSIB report relating to Group B strep. It appears that GBS was never discussed with Miss ████████ at any time during her pregnancy. She was certainly not made aware of the dangers of this infection to her new baby. It would seem that had Miss ████████ been screened for GBS infection and the screen had proved positive she would have been offered antibiotics during labour and the death of baby Reggie Jay may have been avoided. At least 60 countries have a national policy for a form of microbiological screening and antibiotics use during pregnancy to prevent newborn GBS disease. I consider that for the safety of babies born in Milton Keynes, the trust should consider the introduction of a screening program for all pregnant mothers delivering in Milton Keynes. If the screening process proves positive, then antibiotic cover should be offered. This is an area where Milton Keynes could lead the rest of the country and save the lives of many babies. ”

    Source location

    Reggie -Jay John PAYNE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. South Yorkshire (Eastern)

    AI-generated summary

    Isabella Rosa Drew · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Isabella Rosa Drew was a 29-day-old infant who contracted whooping cough in early September 2014 and died on 9 September 2014; the recorded causes of death were severe acute pneumonia and Bordetella pertussis. The report raised concerns that pregnant women were not consistently offered whooping cough vaccination, and that national guidance did not provide sufficient detail on local procedures, auditing, follow-up, and communication between antenatal healthcare providers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of local healthcare provider systems to capture responsibility for advising all pregnant women about the importance of whooping cough vaccination

    Wider context from the report

    “(1) consideration needs to be given as to whether there needs to be further and more explicit guidance as to how local healthcare providers ensure systems put in place effectively capture their responsibility to advise all pregnant women of the importance of whooping cough vaccination with provision for auditing and follow up procedures. ”

    Source location

    Isabella Rosa Drew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026