Kimberley Sampson and Samantha Mulcahy
17 Sept 2023 · Coroner Catherine Wood · Central and South East Kent
The coroner's concerns
1. staff not tested for infection
“Public Health England were involved in the investigation following the deaths and advice on testing staff was unclear which meant neither of the members of staff involved with both women were tested”
2. no guidance on antiviral therapy for post-partum Herpes Simplex
“Herpes Simplex can be fatal if contracted in pregnancy and whilst deaths are rare there is no specific guidance in relation to treating women in the post-partum period with anti-viral therapy”
3. delayed or absent Acyclovir use
“It was accepted by all who gave evidence that antiviral medication would have been the recognised treatment for Herpes Simplex (specifically Acyclovir)”
4. lack of national guidance on antiviral prescribing
“The Trust has made some minor amendments to its protocols but there is no national guidance either in place back in 2018 or currently in 2023 on prescribing antiviral medication to women who present with signs of systemic infection”
5. missed opportunity for early Acyclovir treatment
“Had Acyclovir been prescribed at an earlier stage it is likely to have significantly reduced the risk of death from progression of the disease”
6. insufficient awareness of Herpes Simplex in sepsis pathways
“more needs to be done to raise awareness of it as a potential diagnosis to exclude in sepsis pathways and for early consideration of the use to Acyclovir”