PFD report

Edward Paddon-Bramley · Prevention of Future Deaths report

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Issued 6 Mar 2016•Inner South London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Inconsistent use of intrapartum antibiotics
  2. Inconsistent treatment guidance and practice for prolonged rupture of membranes
  3. Inconsistent GBS screening practice during pregnancy
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Review the recommendation on screening for Group B Streptococcus in pregnancy after the update review and consultation.

    Stated by UK National Screening CommitteeStated plannedThe respondent said that this action was planned when they made their response on 3 March 2016.
  2. Action

    Commission an update review of antenatal screening for Group B Streptococcus carriage.

    Stated by UK National Screening CommitteeStated completedThe respondent said that this action was complete when they made their response on 3 March 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Universal antenatal GBS screening is not offered because testing poorly predicts disease and the benefits and harms are uncertain.

    Stated by UK National Screening CommitteeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inconsistent use of intrapartum antibiotics

Wider context from the report

“Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants. Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture. Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE. In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE. There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inconsistent treatment guidance and practice for prolonged rupture of membranes

Wider context from the report

“Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants. Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture. Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE. In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE. There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inconsistent GBS screening practice during pregnancy

Wider context from the report

“Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants. Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture. Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE. In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE. There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the recommendation on screening for Group B Streptococcus in pregnancy after the update review and consultation.

Verbatim wording from the response

“National screening policy is set by an expert Committee, the UK National Screening Committee (UK NSC), which advises Ministers and the NHS about all aspects of screening policy. In November 2012, the UK NSC recommended that antenatal screening for GBS carriage should not be offered. This is because testing women in late pregnancy to see if they carry GBS is not very effective in predicting whether the baby is likely to be affected by early onset GBS disease. This means that thousands of women in labour who carry GBS as a harmless bacterium would be offered antibiotics they didn’t need. The balance of benefits and harms from this strategy is uncertain. In December 2015 the UK NSC commissioned an update review into antenatal screening for GBS as per its published process. A public consultation is expected to be held in the autumn for a three-month period.”

Source location

2016-0099-Response-by-NSC
Page 1 · response
Published 3 March 2016

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Commission an update review of antenatal screening for Group B Streptococcus carriage.

Verbatim wording from the response

“National screening policy is set by an expert Committee, the UK National Screening Committee (UK NSC), which advises Ministers and the NHS about all aspects of screening policy. In November 2012, the UK NSC recommended that antenatal screening for GBS carriage should not be offered. This is because testing women in late pregnancy to see if they carry GBS is not very effective in predicting whether the baby is likely to be affected by early onset GBS disease. This means that thousands of women in labour who carry GBS as a harmless bacterium would be offered antibiotics they didn’t need. The balance of benefits and harms from this strategy is uncertain. In December 2015 the UK NSC commissioned an update review into antenatal screening for GBS as per its published process. A public consultation is expected to be held in the autumn for a three-month period.”

Source location

2016-0099-Response-by-NSC
Page 1 · response
Published 3 March 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Universal antenatal GBS screening is not offered because testing poorly predicts disease and the benefits and harms are uncertain.

Verbatim wording from the response

“National screening policy is set by an expert Committee, the UK National Screening Committee (UK NSC), which advises Ministers and the NHS about all aspects of screening policy. In November 2012, the UK NSC recommended that antenatal screening for GBS carriage should not be offered. This is because testing women in late pregnancy to see if they carry GBS is not very effective in predicting whether the baby is likely to be affected by early onset GBS disease. This means that thousands of women in labour who carry GBS as a harmless bacterium would be offered antibiotics they didn’t need. The balance of benefits and harms from this strategy is uncertain. In December 2015 the UK NSC commissioned an update review into antenatal screening for GBS as per its published process. A public consultation is expected to be held in the autumn for a three-month period.”

Source location

2016-0099-Response-by-NSC
Page 1 · response
Published 3 March 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Health professionals are advised to follow established NICE and RCOG risk-based guidance for GBS prevention.

Verbatim wording from the response

“In the UK, health professionals are advised to follow the risk-based guidance established by NICE and the RCOG. Though it is not possible to comment on individual cases, it appears that this case is relevant to that guidance. This is because of the prolonged membrane rupture and chorioamnionitis described in your”

Source location

2016-0099-Response-by-NSC
Page 1 · response
Published 3 March 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

NICE and RCOG are better placed to respond to the issues raised about risk-based GBS guidance.

Verbatim wording from the response

“report. I note that NICE and RCOG have received this report and they are better placed to respond to the issues raised. However, it may be of interest to you to know that research is currently underway to evaluate the value of using rapid tests in labour to detect GBS in women with the kind of risk factors experienced by ████████ This is sponsored by the NIHR HTA Programme.”

Source location

2016-0099-Response-by-NSC
Page 2 · response
Published 3 March 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Current evidence does not support universal antenatal screening for group B streptococcal carriage.

Verbatim wording from the response

“The UK National Screening Committee (UK NSC) advises Ministers and the NHS in all four countries about all aspects of screening policy and supports implementation. Using research evidence, pilot programmes and economic evaluation, it assesses the evidence for programmes against a set of internationally recognised criteria. In the case of screening for GBS carriage in pregnancy, the current evidence does not support universal screening.”

Source location

2016-0099-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Monitor developments on vaccines against group B streptococcal infection.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2016.
  2. 2

    Undertake a grant-funded study assessing the potential impact of maternal immunisation against group B streptococcal infection.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2016.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Monitor developments on vaccines against group B streptococcal infection.

Verbatim wording from the response

“A range of work is being taken forward by the Department and Public Health England (PHE) with a range of partner organisations on preventing GBS infection. This includes:”

Source location

2016-0099-Response-by-Department-of-Health
Page 3 · response
Published 3 March 2016

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Undertake a grant-funded study assessing the potential impact of maternal immunisation against group B streptococcal infection.

Verbatim wording from the response

“A range of work is being taken forward by the Department and Public Health England (PHE) with a range of partner organisations on preventing GBS infection. This includes:”

Source location

2016-0099-Response-by-Department-of-Health
Page 3 · response
Published 3 March 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026