Recurance · prevention of future deaths reports
Pre-inquest brief
Inconsistent antenatal CTG interpretation leading to delayed response
The earlier warning
Isa Mushtaq · 24 Sept 2014 · Sara Lewis, Manchester (City)
“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.”
What was promised
No published response from Royal College of Obstetricians and Gynaecologists was found for the earlier reports.
What recurred
- 22 Feb 2017 · Maxim Karpovich · David Hinchliff · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.