Recurance · prevention of future deaths reports
Pre-inquest brief
Misinterpretation of CTG traces leading to missed abnormal fetal heart rate
The earlier warning
Maxim Karpovich · 22 Feb 2017 · David Hinchliff, West Yorkshire (East)
“It was apparent that the Midwives involved with [the deceased]'s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions.”
judiciary.uk/prevention-of-future-death-reports/maxim-karpovich
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 3 Feb 2020 · Harry Richford · Christopher Sutton-Mattocks · Closely related · confidence 0.85 (high)
- 18 Mar 2025 · Alonzo Wood · Joanne Andrews · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Maxim Karpovich · 22 Feb 2017
“It was apparent that the Midwives involved with [the deceased]'s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions.”
Later · Harry Richford · 3 Feb 2020
“There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.”
What happened next
No web check of the stated actions has been published for this chain.