Recurance · prevention of future deaths reports
Pre-inquest brief
Maternal heart rate misinterpreted as fetal heart rate
The earlier warning
Arthur Brockett-Deakins · 25 Feb 2014 · Andrew Harris, London (Inner South)
“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.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 30 Apr 2026 · Poppy Lomas · Andrew Walker · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.