Inconsistent antenatal CTG interpretation leading to delayed response
Royal College of Obstetricians and Gynaecologists received 2 coroners' reports about this hazard between 24 Sept 2014 and 22 Feb 2017.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Royal College of Obstetricians and Gynaecologists was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken.”
Original on judiciary.uk ↗ No published response from Royal College of Obstetricians and Gynaecologists was found for this report.
- 2 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“This training should address pattern recognition, pathophysiology of foetal heart rate changes, clinical scenarios with CTG's and appropriate responses.”
Original on judiciary.uk ↗ Royal College of Obstetricians and Gynaecologists responded.Response (PDF) ↗
- All reports to Royal College of Obstetricians and Gynaecologists
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 → 2017Maxim Karpovich2 years 5 months after Isa Mushtaq · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight deficiencies in interpreting cardiotocograph (CTG) traces that can lead to delayed clinical action. The earlier report focuses on lack of guidance for antenatal CTG, while the later report calls for training to improve intrapartum CTG interpretation.
Isa Mushtaq · 24 Sept 2014
“In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken.”
Original on judiciary.uk ↗ Maxim Karpovich · 22 Feb 2017
“This training should address pattern recognition, pathophysiology of foetal heart rate changes, clinical scenarios with CTG's and appropriate responses.”
Original on judiciary.uk ↗
No published response from Royal College of Obstetricians and Gynaecologists was found for this report.
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 Royal College of Obstetricians and Gynaecologists 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 → 2017 | 0.78 | 0.12 | Closely related · 0.90 | 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.