First reported 25 Feb 2014•Latest report 19 May 2025
Definition
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.
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
8
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
21
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 Care2
National Institute for Health and Care Excellence2
Nursing and Midwifery Council2
Calderdale and Huddersfield NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Healthcare Safety Investigation Branch1
Medicines and Healthcare products Regulatory Agency1
Milton Keynes University Hospital1
Royal College of Midwives1
Royal College of Obstetricians and Gynaecologists1
Stepping Hill Hospital1
the Princess Alexandra Hospital NHS Trust1
Executive non-departmental public body2
Health and care professional regulator2
Healthcare site2
Ministerial department2
NHS trust2
Health professional body1
Local health board1
Medicines and medical devices regulator1
Trade union and professional body1
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.
Essex
Concerns raised1
Failure to ensure consistent understanding and escalation of concerns about labouring mothers and CTG traces for doctor review
This report raised 1 other concern. 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.3
Action
Embed consistent use of Teach or Treat and AID escalation tools through relaunch messaging, training, case-based learning and safety-huddle reinforcement.
Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Hire a Labour Ward, Obstetric and Simulation Lead to provide CTG interpretation and escalation simulations.
Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Participate in the Labour Ward Coordinator Education and Development Framework to strengthen escalation leadership and skills.
Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
West Yorkshire (Western)
Concerns raised1
Failure to recognise non-reassuring CTG signs
This report raised 13 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.1
Action
Provide compulsory annual training for midwives and maternity staff covering CTG monitoring, maternal monitoring and obstetric emergencies.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The doctor’s reflection, assessment, training, subsequent practice and case reviews are considered sufficient to establish competency in managing obstetric emergencies and related concerns.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to closely observe a concerning cardiotocograph
This report raised 9 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.
South Wales Central
Concerns raised1
Poor standard of CTG interpretation
This report raised 9 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.2
Action
Implement All Wales intrapartum fetal surveillance standards, including minimum CTG training.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Introduce competency-based assessment for CTG interpretation and monitor training compliance.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
West Yorkshire Eastern
Concerns raised3
Failure to provide management review and pass-or-fail assessment of midwives' CTG refresher training
Lack of CTG tracing interpretation training in undergraduate midwifery degree syllabuses
Lack of formal annual CTG tracing and interpretation refresher training for practising midwives
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.1
Action
Support the electronic fetal monitoring package in collaboration with the Royal College of Midwives and Health Education England.
Stated by Royal College of Obstetricians and GynaecologistsStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
West Yorkshire Eastern
Concerns raised1
Lack of competence in intrapartum CTG interpretation
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.2
Action
Develop and provide the eFM web-based resource to improve electronic fetal monitoring interpretation and subsequent management.
Stated by Royal College of MidwivesStated completedThe respondent said that this action was complete when they made their response on 5 March 2017.
Action
Support the electronic fetal monitoring package in collaboration with the Royal College of Midwives and Health Education England.
Stated by Royal College of Obstetricians and GynaecologistsStated in progressThe respondent said that this action was in progress when they made their response on 5 March 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A theoretical course for all trainees is considered impractical because trainees struggle to obtain study leave and face extensive mandatory training.
Stated by Royal College of Obstetricians and GynaecologistsUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
An additional universal CTG course is not considered to enhance safety because the existing curriculum and team-based training arrangements address the relevant risks.
Stated by Royal College of Obstetricians and GynaecologistsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Milton Keynes
Concerns raised2
Failure to provide effective senior support for abnormal CTG monitoring
Lack of leadership authority to require timely doctor attendance and CTG review
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.
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.7
Action
Strengthen newly qualified midwives’ preceptorship through supernumerary supported practice with experienced senior midwives.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Provide two-hourly Band 7 coordinator rounding for patients receiving one-to-one care.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Introduce ‘fresh eyes/ears’ stickers to ensure hourly senior review of intermittent and continuous fetal monitoring.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Change the patient whiteboard to record the doctor-review time for suspicious CTG traces.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2015.
Action
Embed a revised SBAR handover communication tool in practice.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Recirculate the written escalation policy to all staff.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The concerns were identified and appropriately escalated; junior midwives are qualified and understand how to summon emergency assistance.
Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The CTG did not require immediate intervention, and staff escalated appropriately when the doctor did not attend within a reasonable timescale.
Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clear escalation instructions already exist for all midwifery and medical staff, including escalation to a consultant.
Stated by Milton Keynes University Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner South London
Concerns raised2
Insufficient CTG interpretation training and competence
Failure to escalate abnormal CTG findings appropriately in slow second-stage labour
This report raised 6 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.6
Action
Update the Intrapartum Care clinical guideline, including fetal assessment and monitoring recommendations.
Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 25 February 2014.
Action
Consult stakeholders on the draft Intrapartum Care guideline recommendations between 13 May and 24 June 2014.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 25 February 2014.
Action
Publish the final updated Intrapartum Care clinical guideline in October 2014.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 25 February 2014.
Action
Publish and disseminate safety advice warning healthcare professionals about risks in interpreting CTG traces.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 25 February 2014.
Action
Revise CTG-use safety advice and issue current guidance as MDA 2010/054.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 25 February 2014.
Action
Publish a maternity edition of One Liners highlighting issues in interpreting CTG readings.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 25 February 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The actions of either midwife concerning the death cannot be reconsidered because the referral was previously closed and no legal exception applies.
Stated by Nursing and Midwifery CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The evidence does not support a significant change to recommendations on fetal assessment and monitoring, although recommendations may be strengthened.
Stated by National Institute for Health and Care ExcellenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clinicians retain responsibility for treatment decisions and may depart from NICE guidelines for appropriate, documented clinical reasons.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes deficiencies specifically dedicated to intrapartum CTG competence, interpretation, monitoring, review or escalation, including training and assessment that directly govern those functions.
