Review of Group B Strep claims identifies missed opportunities in maternity care

The review of Group B Strep claims reported to NHS Resolution found that only one in four babies received antibiotics within the nationally recognised one-hour target after sepsis was suspected, while more than three-quarters became symptomatic within the first 24 hours of life. Together, the findings highlight the importance of recognising neonatal sepsis early and ensuring prompt treatment to reduce the risk of avoidable harm.

What is Group B Strep?

Group B Streptococcus (GBS) is a common bacterium that is usually harmless in adults but can sometimes pose a significant risk to newborns, particularly if transmitted during childbirth. Infection in newborns can lead to sepsis, pneumonia or meningitis. Newborns can develop GBS infections either early onset (within the first week of life) or late onset (from one week to three months after birth).

A closer look at the findings

The report published by NHS Resolution examined 19 closed clinical negligence claims relating to Early Onset Group B Streptococcal disease (EOGBS) between January 2016 and March 2023. While this represents only a small proportion of maternity negligence claims, the cases provide valuable insight into recurring factors that contributed to avoidable harm in maternity and neonatal care.

Neonatal mortality in this cohort was 53%. This is significantly higher than the expected population mortality for EOGBS disease in England of 5.2%.

Across the review, NHS Resolution identified 81 separate allegations and learning points grouped into five themes:

1. Mismanagement of labour and intrapartum antibiotic prophylaxis (38%)
2. Delays in recognising and managing the unwell baby (22%)
3. Problems related to human factors and documentation (14%)
4. Issues regarding maternal screening and testing (14%)
5. Delays in recognising maternal sepsis (12%)

Some specific examples include:

• Only 25% of babies received antibiotics within the nationally recognised one-hour target after sepsis was suspected. Early antibiotic treatment is critical in reducing the risk of serious complications from neonatal sepsis, delays in diagnosis and treatment remain a key patient safety concern.
• 76% of babies became symptomatic within the first 24 hours after birth. Poor feeding, jaundice and babies appearing generally unwell were among the most common early warning signs recorded across the claims. These findings reinforce the importance of robust postnatal monitoring and the consistent use of early warning tools enabling healthcare professionals to identify deterioration and support timely escalation.
• Communication failures featured prominently throughout the claims. Rather than questioning decisions about whether women should be tested for GBS, many cases related to failures in managing positive test results, delays in reviewing laboratory findings, poor communication between clinical teams and missed opportunities to administer intrapartum antibiotics.

Jason said “Although this review examined a relatively small number of claims, the finding are significant because they reveal recurring themes rather than isolated mistakes. Many of the cases involved a series of missed opportunities, whether that’s recognising the early signs of sepsis, acting on test results, administering antibiotics promptly or escalating concerns appropriately.

“While not every adverse outcome is avoidable, these findings demonstrate the importance of robust clinical systems, effective communication and adherence to national guidance. Reviews such as this are essential because they help identify where improvements can be made to reduce the risk of similar incidents occurring in the future.”

The findings also align with wider national priorities to improve maternity safety. The themes identified by NHS Resolution reflect the recommendations of the Ockenden Review (June 2026), the principles set out in the NHS Constitution and the ambitions of the Government’s Fit for the Future: 10 Year Health Plan for England, all of which emphasise the importance of delivering safe, high-quality care, learning from incidents and strengthening systems to reduce avoidable harm for mothers and babies.

Notes:

The full report can be accessed here: Learning from claims related to early onset Group B Streptococcal disease in neonates – NHS Resolution