Recurring concern
Unreliable centralised CTG monitoring systems
- Reports that mention this concern
- 2
- Times this concern has been raised
- 2
- Stated actions linked to this concern
- 3
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
-
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.
Linked responses
- Chelsea and Westminster Hospital NHS Foundation Trust
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Chelsea and Westminster Hospital NHS Foundation Trust
Update intrapartum fetal monitoring guidance to require bedside CTG confirmation and hourly holistic review with discussion between clinicians.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
The Maternity and Neonatal Programme cannot comment on local CTG review practice or guidance.
-
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.
Linked response
- Homerton Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Homerton Healthcare NHS Foundation Trust
Establish and approve a local policy for centralised CTG monitoring.
-
Homerton Healthcare NHS Foundation Trust
Circulate the approved centralised CTG monitoring policy to staff and include it in daily handovers.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026