First reported 7 Oct 2014•Latest report 8 Apr 2021
Definition
What this concern includes
Includes failures of dedicated fetal-monitoring arrangements, including deciding when monitoring is required, specifying the method or frequency, communicating requirements, completing monitoring and assuring that staff follow the applicable regime during labour, obstetric procedures or other clinically relevant maternity care.
Not included
Excludes failures limited to interpreting CTG traces or escalating abnormal CTG findings where the fetal monitoring itself was performed reliably.
Excludes generic maternity staffing, communication, training or documentation deficiencies unless they directly impair clinically required fetal monitoring.
Excludes fetal-growth measurement, birth-mode decision-making and general antenatal assessment where fetal monitoring is not the unsafe condition.
Excludes monitoring hazards involving equipment malfunction or maternal pulse displayed as fetal heart rate unless the assertion also identifies failure of the fetal-monitoring process itself.
Reports
7
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2014–2021
First to latest report issue date
Stated actions
12
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 Care3
Betsi Cadwaladr University LHB1
East and North Hertfordshire Teaching NHS Trust1
HCA Healthcare UK The Portland Hospital1
Healthcare Safety Investigation Branch1
Manchester University NHS Foundation Trust1
National Institute for Health and Care Excellence1
North Tyneside General Hospital1
Northumbria Healthcare NHS Foundation Trust1
Royal College of Obstetricians and Gynaecologists1
Stepping Hill Hospital1
Walsall Healthcare NHS Trust1
Ysbyty Gwynedd1
Healthcare site4
NHS trust4
Ministerial department3
Executive non-departmental public body1
Health professional body1
Local health board1
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.
West London
Concerns raised1
Failure to ensure fetal monitoring requirements during epidural siting are highlighted and followed
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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 respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Implement clarified midwifery and anaesthetic responsibilities, including maintaining fetal monitoring and providing backup support during epidural insertion.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
Action
Conduct monthly audits to monitor whether the fetal-monitoring and staffing changes are embedded and identify potential issues.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
Action
Update the Fetal Monitoring and Epidural Analgesia in Labour policies to clarify staff responsibilities during epidural insertion.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
Action
Disseminate the clarified responsibilities through team meetings, multidisciplinary circulation and skills-and-drills training.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
Hertfordshire
Concerns raised1
Failure in basic medical care for foetal heart rate monitoring and management during labour
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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 respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Enhance fetal monitoring training, including second-stage labour interpretation, maternal-pulse recognition, human factors and incident learning.
Stated by East and North Hertfordshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Action
Employ a full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.
Stated by East and North Hertfordshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Roll out an intermittent auscultation and escalation competency package with case scenarios, small-group and annual training, competency assessment and pass-rate auditing.
Stated by East and North Hertfordshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Action
Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.
Stated by East and North Hertfordshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Action
Introduce a CTG-machine sticker requiring two independent maternal-pulse checks and signatures after transfer from MLU to CLU.
Stated by East and North Hertfordshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Action
Develop and implement planned CTG interpretation and escalation actions to establish a robust process.
Stated by East and North Hertfordshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Action
Award £9.4 million to support maternity safety pilots using investigation and research learning, training and expert guidance to improve childbirth practice.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS Trusts are responsible for implementing the Saving Babies’ Lives Care Bundle and appointing fetal-monitoring leads.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Black Country
Concerns raised1
Lack of waterproof equipment for foetal heart rate auscultation during birthing pool births
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised2
Failure to closely observe a concerning cardiotocograph
Failure to review cardiotocography after induction of labour commenced
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Newcastle upon Tyne
Concerns raised1
Failure to use Foetal Scalp Electrodes for critical fetal distress information
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester (West)
Concerns raised2
Failure to formally record the exact time of cessation of fetal heart activity
Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North Wales (East and Central)
Concerns raised1
Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Pin
Get email alerts
Request correction
Includes failures of dedicated fetal-monitoring arrangements, including deciding when monitoring is required, specifying the method or frequency, communicating requirements, completing monitoring and assuring that staff follow the applicable regime during labour, obstetric procedures or other clinically relevant maternity care.
