Recurring concern

Unreliable intrapartum CTG interpretation and escalation

First to latest report 25 Feb 2014 — 19 May 2025

Reports that mention this concern
8
Times this concern has been raised
12
Stated actions linked to this concern
21

What this concern includes

Includes deficiencies specifically dedicated to intrapartum CTG competence, interpretation, monitoring, review or escalation, including training and assessment that directly govern those functions.

What is not included
  • General maternity staffing, communication or escalation deficiencies where intrapartum CTG is not the deficient control.
  • Fetal monitoring systems unrelated to intrapartum CTG.
  • Treatment or delivery decisions after CTG findings were competently interpreted and escalated.

Reports and published responses 8 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Emmy Russo · 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

    Emmy Russo was born in very poor condition after a hypoxic injury shortly before birth and died following severe hypoxic-ischaemic brain injury. The report raised concerns about information given to patients considering induction beyond 41 weeks and about inconsistent escalation of concerns regarding labouring mothers and CTG traces for medical review. The inquest identified missed opportunities to deliver Emmy sooner.

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    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 ensure consistent understanding and escalation of concerns about labouring mothers and CTG traces for doctor review

    Wider context from the report

    “(2) The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review. Evidence was given on the measures put in place to address issues with escalation, including “Teach or Treat” and “AID” tools, however, there was limited evidence that these are understood by the working midwives and/or advertised to them by way of regular reminders. ”

    Source location

    Emmy Russo · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Embed consistent use of Teach or Treat and AID escalation tools through relaunch messaging, training, case-based learning and safety-huddle reinforcement.

    Verbatim wording from the response

    “The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review. Evidence was given on the measures put in place to address issues with escalation, including “Teach or Treat” and “AID” tools, however, there was limited evidence that these are understood by the working midwives and/or advertised to them by way of regular reminders.”

    Source location

    Response from Princess Alexandra Hospital NHS Foundation Trust
    Page 3 · response
    Published 21 May 2025

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    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

    Hire a Labour Ward, Obstetric and Simulation Lead to provide CTG interpretation and escalation simulations.

    Verbatim wording from the response

    “14 In addition to this, the Trust is currently hiring a Labour Ward, Obstetric and Simulation Lead. As part of this role, the Consultant Obstetrician appointed will be responsible for providing simulations to the team which will include issues of both CTG interpretation and escalation.”

    Source location

    Response from Princess Alexandra Hospital NHS Foundation Trust
    Page 3 · response
    Published 21 May 2025

    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

    Participate in the Labour Ward Coordinator Education and Development Framework to strengthen escalation leadership and skills.

    Verbatim wording from the response

    “17 Further to this, the Trust is actively participating in the Labour Ward Coordinator Education and Development Framework. This is a national programme, focused on strengthening the leadership of Labour Ward Coordinators. The framework aims to enhance the quality of care provided in Labour Wards and will strengthen clinicians skills to escalate care appropriately.”

    Source location

    Response from Princess Alexandra Hospital NHS Foundation Trust
    Page 4 · response
    Published 21 May 2025

    Open published response

  2. West Yorkshire (Western)

    AI-generated summary

    Edward Arthur AKROYD · 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

    Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.

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    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 recognise non-reassuring CTG signs

    Wider context from the report

    “7. The same registrar in evidence stated that it was his view at the time and also from the position of hindsight, that the ctg trace showed no significant cause for concern until shortly before he made the decision that Mrs Akroyd Should undergo a forceps delivery. I heard evidence from a number of consultants that the ctg trace from shortly after its commencement was showing non reassuring signs which should together with other facts have resulted in an earlier delivery of Edward and if this had occurred it is likely he would have survived. I am concerned that if the same facts were to reoccur, and a similar interpretation of a ctg trace was to be made, it poses a risk to the expectant mother and her unborn child. ”

    Source location

    Edward Arthur AKROYD · Prevention of Future Deaths report
    Page 3 · concerns

    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

    Provide compulsory annual training for midwives and maternity staff covering CTG monitoring, maternal monitoring and obstetric emergencies.

    Verbatim wording from the response

    “In terms of disseminating guidance, refreshing the knowledge of staff and monitoring compliance: All new and revised guidelines are placed on the Trust’s intranet and are available at any time electronically. The weekly Maternity Risk Management Newsletter will have a notice about new or revised guidelines. The compulsory annual Obstetric Emergency Training Day contains reminders about these guidelines.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 2 · response
    Published 8 March 2022

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    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

    The doctor’s reflection, assessment, training, subsequent practice and case reviews are considered sufficient to establish competency in managing obstetric emergencies and related concerns.

    Verbatim wording from the response

    “He has reflected on this case with his clinical supervisors and with a number of consultant colleagues. He has had annual appraisals and undergone the vigorous process of assessment and was awarded a CESR certificate and recognised on the specialist register by the GMC on 30 November 2020. Since his involvement in Mrs Akroyd’s care, he has since progressed to a substantive Consultant post at the Trust.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 5 · response
    Published 8 March 2022

    Open published response

  3. Manchester South

    AI-generated summary

    Xander Curran-Pass · 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

    Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.

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    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 closely observe a concerning cardiotocograph

    Wider context from the report

    “9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed; ”

    Source location

    Xander Curran-Pass · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Wales Central

    AI-generated summary

    Jenson James Francis · 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

    Jenson James Francis was delivered by caesarean section and developed chorioamnionitis and funisitis in the context of maternal sepsis. The report records cardio-pulmonary failure following a failure to deliver him in good time and states that he was exposed to the effects of developing maternal sepsis. Principal concerns included poor CTG interpretation and training, unclear clinical leadership and communication, inadequate records, insufficient staffing and escalation, and wider systemic shortcomings in the maternity unit.

    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

    Poor standard of CTG interpretation

    Wider context from the report

    “(2) There was a poor standard of CTG interpretation, with insufficient training and review ”

    Source location

    Jenson James Francis · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Implement All Wales intrapartum fetal surveillance standards, including minimum CTG training.

    Verbatim wording from the response

    “The Health Board has implemented the All Wales Intrapartum Fetal Surveillance Standards which includes a minimum of 6 hours of taught training on CTG monitoring & interpretation. WRP are supporting the introduction of a competency based assessment for CTG interpretation. Training compliance is being monitored through Maternity Improvement Board.”

    Source location

    2019-0158-Response-by-University-Health-Board
    Page 2 · response
    Published 28 July 2019

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    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

    Introduce competency-based assessment for CTG interpretation and monitor training compliance.

    Verbatim wording from the response

    “The Health Board has implemented the All Wales Intrapartum Fetal Surveillance Standards which includes a minimum of 6 hours of taught training on CTG monitoring & interpretation. WRP are supporting the introduction of a competency based assessment for CTG interpretation. Training compliance is being monitored through Maternity Improvement Board.”

    Source location

    2019-0158-Response-by-University-Health-Board
    Page 2 · response
    Published 28 July 2019

    Open published response

  5. West Yorkshire Eastern

    AI-generated summary

    Billy Wilson · 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

    Billy Wilson was born at Pinderfields Hospital and died aged three days after suffering hypoxic-ischaemic brain injury and perinatal asphyxia. The report describes continued use and increased dosing of syntocinon despite abnormal foetal monitoring, hyperstimulation and signs of foetal distress. It raises concerns about inadequate training and assessment in cardiotocograph interpretation for student, newly qualified and practising midwives.

    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 management review and pass-or-fail assessment of midwives' CTG refresher training

    Wider context from the report

    “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country. (2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken. (3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation. (4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and assessment. ”

    Source location

    Billy Wilson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of CTG tracing interpretation training in undergraduate midwifery degree syllabuses

    Wider context from the report

    “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country. (2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken. (3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation. (4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and assessment. ”

    Source location

    Billy Wilson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of formal annual CTG tracing and interpretation refresher training for practising midwives

    Wider context from the report

    “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country. (2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken. (3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation. (4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and assessment. ”

    Source location

    Billy Wilson · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Support the electronic fetal monitoring package in collaboration with the Royal College of Midwives and Health Education England.

    Verbatim wording from the response

    “However I should mention here that, as the official host, the RCOG has put a significant amount of resource into supporting the eFM package, working with the Royal College of Midwives and Health Education England.”

    Source location

    Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
    Page 1 · response
    Published 5 March 2017

    Open published response

  6. West Yorkshire Eastern

    AI-generated summary

    Maxim Karpovich · 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

    Baby Maxim Karpovich was delivered by emergency caesarean section on 16 March 2015 with no signs of life, was resuscitated and treated in the Neonatal Intensive Care Unit, and died later that day. The concerns included failures to recognise and correctly interpret abnormal cardiotocograph traces, together with wider concerns about the adequacy of CTG interpretation training and competency assessment for midwives and obstetricians.

    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

    Lack of competence in intrapartum CTG interpretation

    Wider context from the report

    “(1) It was apparent that the Midwives involved with Maxim’s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions. The Obstetric Registrar, at 2357 hours, incorrectly classified the CTG to be normal when it clearly was not. The baby, Maxim, who was delivered by an emergency caesarean section. Expert evidence stated that if the caesarean section had been carried out by midnight, the baby would have survived, although there could have been some neurological deficit. (2) This Inquest and many others previously, have caused me to note that Midwives and Obstetricians lack the core skills to interpret CTG tracings for intrapartum care. ”

    Source location

    Maxim Karpovich · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Develop and provide the eFM web-based resource to improve electronic fetal monitoring interpretation and subsequent management.

    Verbatim wording from the response

    “The RCM in partnership with the Royal College of Obstetricians and Gynaecologists and Health Education England e-Learning for Healthcare developed a comprehensive web-based resource called eFM: an e-learning resource aimed at improving the interpretation of electronic fetal monitoring and subsequent management. This is a free resource for all employees of the National Health Service and contains knowledge-based interactive tutorials, assessments and case studies.”

    Source location

    Response-from-Royal-College-of-Midwives
    Page 2 · response
    Published 5 March 2017

    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

    Support the electronic fetal monitoring package in collaboration with the Royal College of Midwives and Health Education England.

    Verbatim wording from the response

    “However I should mention here that, as the official host, the RCOG has put a significant amount of resource into supporting the eFM package, working with the Royal College of Midwives and Health Education England.”

    Source location

    Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
    Page 1 · response
    Published 5 March 2017

    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

    A theoretical course for all trainees is considered impractical because trainees struggle to obtain study leave and face extensive mandatory training.

    Verbatim wording from the response

    “Thank you for writing to me on 22 February and 8 March 2017 regarding the inquest of the deaths of Maxim Karpovich and Billy Wilson. I responded to ████████ on 17 March 2017 after meeting and discussing with the RCOG Officers and seeking input and advice from the new Vice Presidents of Education and Clinical Quality. I apologised to ████████ for the delay in my response explaining that I needed to consult with the Curriculum Review team in some detail before I could address his concerns appropriately. The consensus from the RCOG Officers and the Curriculum Review team was that a theoretical course in itself – particularly a course taking place over many weeks as has been suggested – was unrealistic for all trainees, many of whom are struggling to obtain study leave from their Trusts and are also complaining bitterly about the mandatory training modules that they are expected to complete.”

    Source location

    Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
    Page 1 · response
    Published 5 March 2017

    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

    An additional universal CTG course is not considered to enhance safety because the existing curriculum and team-based training arrangements address the relevant risks.

    Verbatim wording from the response

    “In terms of the new curriculum, the pressure of completing modules does not allow us to increase the emphasis on CTG interpretation but it will remain an important that trainees evidence this skill. The RCOG opinion on CTG interpretation is that the problems arise in clinical practice when the whole picture is not considered, and this is why trainees are encouraged to demonstrate clinical competence within teams as part of workplace based assessments. In addition senior trainees who are likely to be in charge of such teams can register for our Advanced Training Skills Module (ATSM) in advanced antenatal practice or advanced labour ward practice, both of which contain curricula that deliver additional training in the teamwork around CTG interpretation which includes the running of team meetings and reviews of decision making.”

    Source location

    Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
    Page 2 · response
    Published 5 March 2017

    Open published response

  7. Milton Keynes

    AI-generated summary

    Ethan Robert Johnson · 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

    Ethan Johnson was born following an urgent Caesarean section, with no respiratory effort or heart rate, and died after intensive care treatment was withdrawn. The concerns included a lack of effective leadership, support and escalation when an abnormal CTG was identified. The inquest concluded that delayed delivery resulted in a lost opportunity to deliver him earlier and provide further medical treatment.

    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 effective senior support for abnormal CTG monitoring

    Wider context from the report

    “(1)That the most junior member of staff (midwife) was left to look after ████████ even though the CTG trace was deemed abnormal. The midwife felt unsupported. ”

    Source location

    Ethan Robert Johnson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of leadership authority to require timely doctor attendance and CTG review

    Wider context from the report

    “(2) Two further members of staff reviewed the CTG trace and yet it appears that no one was in a position of leadership to require a doctor to attend and review the trace and ████████ ”

    Source location

    Ethan Robert Johnson · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Strengthen newly qualified midwives’ preceptorship through supernumerary supported practice with experienced senior midwives.

    Verbatim wording from the response

    “In response to your concern, however, the new Head of Midwifery has strengthened the preceptorship period for newly qualified midwives. This means that they are supernumerary for several weeks and will be supported by experienced senior practice development midwives, whilst being familiarised in departmental processes.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 1 · response
    Published 29 September 2015

    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

    Provide two-hourly Band 7 coordinator rounding for patients receiving one-to-one care.

    Verbatim wording from the response

    “Furthermore, 2 hourly ‘intentional rounding’ of all patients undergoing 1:1 care (antenatal, labour, and postnatal) by a Band 7 Co-ordinator is now in place to ensure that appropriate care is being given through support of the patient’s individual midwife.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 1 · response
    Published 29 September 2015

    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

    Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.

    Verbatim wording from the response

    “On the ward the CTG did not require immediate intervention, so when the doctor had not attended within a reasonable timescale it was escalated appropriately. We have written to every member of staff clarifying their responsibilities if they are asked to review a patient, as well as what to do if senior help has been unable to attend. This includes timescales for upward escalation.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 2015

    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

    Introduce ‘fresh eyes/ears’ stickers to ensure hourly senior review of intermittent and continuous fetal monitoring.

    Verbatim wording from the response

    “‘Fresh eyes/ears’ stickers have been introduced to ensure hourly senior review of both intermittent and continuous fetal monitoring.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 2015

    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

    Change the patient whiteboard to record the doctor-review time for suspicious CTG traces.

    Verbatim wording from the response

    “management plan. The department is also in the process of changing the existing patient whiteboard, to include time of doctor review in cases where the CTG trace is deemed suspicious.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 2015

    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

    Embed a revised SBAR handover communication tool in practice.

    Verbatim wording from the response

    “A new, specifically dedicated Matron for Labour Ward has ensured that a revised handover communication tool (SBAR) is embedded in practice, so that a succinct common language is in place to enable the medical staff to make an appropriate assessment of when to attend. There is now a Manager of the Day on the Maternity Unit.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 2015

    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

    Recirculate the written escalation policy to all staff.

    Verbatim wording from the response

    “There are existing clear instructions for all midwifery staff, from new Band 5 Midwife to Matron level and also for all levels of medical staff in respect of escalation to a Consultant.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 3 · response
    Published 29 September 2015

    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

    The concerns were identified and appropriately escalated; junior midwives are qualified and understand how to summon emergency assistance.

    Verbatim wording from the response

    “In this particular case the concerns were identified and appropriately escalated within a few minutes. All our junior midwives are fully qualified and are conversant with the escalation process and how to summon help in an emergency. All staff have been reminded of this process.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 1 · response
    Published 29 September 2015

    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

    The CTG did not require immediate intervention, and staff escalated appropriately when the doctor did not attend within a reasonable timescale.

    Verbatim wording from the response

    “On the ward the CTG did not require immediate intervention, so when the doctor had not attended within a reasonable timescale it was escalated appropriately. We have written to every member of staff clarifying their responsibilities if they are asked to review a patient, as well as what to do if senior help has been unable to attend. This includes timescales for upward escalation.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 2015

    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

    Clear escalation instructions already exist for all midwifery and medical staff, including escalation to a consultant.

    Verbatim wording from the response

    “There are existing clear instructions for all midwifery staff, from new Band 5 Midwife to Matron level and also for all levels of medical staff in respect of escalation to a Consultant.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 3 · response
    Published 29 September 2015

    Open published response

  8. Inner South London

    AI-generated summary

    Arthur Brockett-Deakins · 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

    Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led service.

    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

    Insufficient CTG interpretation training and competence

    Wider context from the report

    “2. Training of one midwife in CTG interpretation: Both midwives underwent voluntary further training and supervision, including an expert workshop on CTG interpretation. Both accepted that a number of errors had been made by them and applied the learning to their current practice. However even in retrospect, one of the midwives could not accept that the early CTG trace was pathological, as held by both expert obstetrician and midwife. Although she would refer now, there is doubt about the urgency. She said in court it would be within half an hour but also that 40 minutes was needed to see if it was abnormal. The expert midwife said that she needed further training on CTG interpretation. ”

    Source location

    Arthur Brockett-Deakins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 escalate abnormal CTG findings appropriately in slow second-stage labour

    Wider context from the report

    “1. When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007, which advises that a 40 minutes trace should be studied before concluding if it is abnormal. Expert evidence from Dr ████████ and Ms ████████ suggested that this guidance was appropriate in the first stage of labour, but not in the context in this case, namely a slow second stage. ”

    Source location

    Arthur Brockett-Deakins · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Update the Intrapartum Care clinical guideline, including fetal assessment and monitoring recommendations.

    Verbatim wording from the response

    “We review all of our guidance at regular intervals and also consider feedback and requests for updates where this is appropriate. Our clinical guideline on Intrapartum Care (CG55) is currently being updated. The progress of the update can be monitored via our website (http://guidance.nice.org.uk/CGWaveR/109).”

    Source location

    2014-0077-Response-by-N.I.C.E
    Page 2 · response
    Published 25 February 2014

    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

    Consult stakeholders on the draft Intrapartum Care guideline recommendations between 13 May and 24 June 2014.

    Verbatim wording from the response

    “We will consult on the draft recommendations with stakeholders between 13th May – 24th June 2014 and the final guideline will be published in October 2014.”

    Source location

    2014-0077-Response-by-N.I.C.E
    Page 2 · response
    Published 25 February 2014

    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

    Publish the final updated Intrapartum Care clinical guideline in October 2014.

    Verbatim wording from the response

    “We will consult on the draft recommendations with stakeholders between 13th May – 24th June 2014 and the final guideline will be published in October 2014.”

    Source location

    2014-0077-Response-by-N.I.C.E
    Page 2 · response
    Published 25 February 2014

    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

    Publish and disseminate safety advice warning healthcare professionals about risks in interpreting CTG traces.

    Verbatim wording from the response

    “One of our predecessor Agencies, The Medical Devices Agency (MDA), published and disseminated a Safety Notice to relevant healthcare professionals in August 2002, warning of the risks associated with the interpretation of CTG traces. This Safety Notice, MDA SN2002(23), was extant in 2007 and a copy is appended to this letter.”

    Source location

    2014-0077-Response-by-Medicines-Healthcare-Products-Regulatory-Agency
    Page 1 · response
    Published 25 February 2014

    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

    Revise CTG-use safety advice and issue current guidance as MDA 2010/054.

    Verbatim wording from the response

    “Our advice on CTG use was revised in 2010 to become MDA 2010/054, and is our current advice.”

    Source location

    2014-0077-Response-by-Medicines-Healthcare-Products-Regulatory-Agency
    Page 2 · response
    Published 25 February 2014

    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

    Publish a maternity edition of One Liners highlighting issues in interpreting CTG readings.

    Verbatim wording from the response

    “In June 2013, MHRA published a special maternity edition of ‘One Liners’, which again highlighted the issues of interpreting CTG readings.”

    Source location

    2014-0077-Response-by-Medicines-Healthcare-Products-Regulatory-Agency
    Page 2 · response
    Published 25 February 2014

    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

    The actions of either midwife concerning the death cannot be reconsidered because the referral was previously closed and no legal exception applies.

    Verbatim wording from the response

    “The NMC will not, however, be able to consider the actions of either midwife in relation to the death of Arthur. This is because that aspect of the referral was considered fully, and closed, by our investigating committee (IC) in 2009. Since the case was closed over three years ago, it cannot be reconsidered by the IC under rule 7(1) of the NMC’s Fitness to Practise Rules 2004. There is also no evidence of an error which would allow us to remit the case back to the committee in accordance with case law in this area (R (on the application of B) v NMC [2012] EWHC 1264 (Admin)).”

    Source location

    2014-0077-Response-by-Nursing-Midwifery-Council
    Page 1 · response
    Published 25 February 2014

    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

    The evidence does not support a significant change to recommendations on fetal assessment and monitoring, although recommendations may be strengthened.

    Verbatim wording from the response

    “The team working on updating this guideline have re-examined the evidence on fetal assessment and monitoring during labour. This specifically includes cardiotocography on admission to the labour ward and during labour and the definition and interpretation of the features of fetal heart rate trace. Whilst I am not able to anticipate the outcome of the final guideline, I can report that we have found no evidence to support a significant change in the recommendations but they have been further strengthened where appropriate.”

    Source location

    2014-0077-Response-by-N.I.C.E
    Page 2 · response
    Published 25 February 2014

    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

    Clinicians retain responsibility for treatment decisions and may depart from NICE guidelines for appropriate, documented clinical reasons.

    Verbatim wording from the response

    “We have confidence that our guidance, correctly implemented, will provide the best outcomes for patients but clinicians retain the responsibility for their decisions. NICE Clinical Guidelines are not mandated and clinical staff can depart from them if there are appropriate and documented clinical reasons for doing so.”

    Source location

    2014-0077-Response-by-N.I.C.E
    Page 2 · response
    Published 25 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026