Alonzo Wood
18 Mar 2025 · Coroner Joanne Andrews · West Sussex, Brighton and Hove
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. insufficient guidance on management of abnormal antenatal CTG
“clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery.”
This report
“clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG”
Closely relatedConfidence 0.80 · moderate
Earlier report
“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.”
This report
“During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG.”
Responses
2025-0152-Response-from-NICE.pdf ↗· National Institute for Health and Care Excellence
2025-0152-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists.pdf ↗· Royal College of Obstetricians and Gynaecologists
Stated action
“the RCOG fully supports and recommends Element 3 of NHS England's Saving Babies Lives Care Bundle version 2 which recommends the use of computerised CTG (fetal heart monitoring) during antenatal period and states the following (page 21): When the available evidence is inconclusive, SBLCBv2 aims to implement pragmatic best practice care, based upon clinical experience and a recognition of the important human factors. Human error in antepartum CTG interpretation has been identified as a significant”