Recurring concern
Unreliable centralised CTG monitoring systems
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Request correctionFirst reported 17 Dec 2021•Latest report 2 Dec 2024
What this concern includes
Includes failures in the dedicated centralised CTG monitoring process, including local governance and operating policy, allocation of responsibility, display and technical use, regular review of centrally monitored CTGs, escalation of concerning traces and assurance that the system is used as intended.
Not included
- Excludes general CTG interpretation training or competence failures where centralised monitoring is not the deficient process.
- Excludes fetal monitoring, CTG acquisition or interpretation failures that are unrelated to a centralised monitoring board or equivalent centralised CTG system.
- Excludes failures occurring after a centrally monitored CTG has been reliably reviewed and escalated, including downstream obstetric treatment or delivery decisions.
- Excludes generic maternity staffing, communication, documentation or governance deficiencies unless they directly impair centralised CTG monitoring.
- Reports
- 2
- Individual concerns
- 2
- Date range
- 2021–2024
- Stated actions
- 3
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of a regular CTG review system on the central CTG monitoring board
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 concernsEach 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
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Action
Update intrapartum fetal monitoring guidance to require bedside CTG confirmation and hourly holistic review with discussion between clinicians.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Maternity and Neonatal Programme cannot comment on local CTG review practice or guidance.
Stated by NHS England
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Concerns raised1
Lack of a local policy for use of centralised CTG monitoring
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 concernsEach 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
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Action
Establish and approve a local policy for centralised CTG monitoring.
Stated by Homerton Healthcare NHS Foundation Trust -
Action
Circulate the approved centralised CTG monitoring policy to staff and include it in daily handovers.
Stated by Homerton Healthcare NHS Foundation Trust
Data last updated 7 September 2026