Maternal heart rate misinterpreted as fetal heart rate
Department of Health and Social Care received 2 coroners' reports about this hazard between 25 Feb 2014 and 30 Apr 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 12 years 2 months laterClosely relatedConfidence 0.85 · higha different coroner
“It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate.”
Original on judiciary.uk ↗ Repeated from the earlier report:pulsematernal
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2026Poppy Lomas12 years 2 months after Arthur Brockett-Deakins · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight a lack of reliable maternal heart rate monitoring that can lead to confusion between maternal and fetal heart rates. The earlier report notes missing maternal ECG/pulse oximetry in CTG machines; the later report notes the absence of a pulse oximeter in home delivery kits.
Arthur Brockett-Deakins · 25 Feb 2014
“The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same.”
Original on judiciary.uk ↗ Poppy Lomas · 30 Apr 2026
“It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2026 | 0.59 | 0.29 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.