Isa Mushtaq
24 Sept 2014 · Coroner Sara Lewis · Manchester (City)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. inconsistent interpretation of antenatal CTG leading to delayed or inappropriate response
“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”
2. misapplication of intrapartum CTG guidance to antenatal monitoring
“Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because: (i) It is not intended for such use and therefore such practice is arguably not evidence based (ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally. (iii) Only a very”
3. lack of national guidance for antepartum CTG abnormalities
“There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007”
This report
“Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:”
Closely relatedConfidence 0.90 · high
This report
“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 report
“This training should address pattern recognition, pathophysiology of foetal heart rate changes, clinical scenarios with CTG's and appropriate responses.”
Identical hazardConfidence 0.90 · high
This 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.”
Later 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”
Responses
No published response was found on judiciary.uk.