Absence of cardiotocography monitoring in maternity settings
Department of Health and Social Care received 2 coroners' reports about this hazard between 27 Nov 2017 and 31 Dec 2021.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“the HSIB will investigate around 1,000 cases a year with the expectation that the learning from investigations will spur system improvements leading to fewer deaths and injuries in the future.”
Stated timescale: April 2019
- 4 years 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“During the inquest it was accepted that CTG monitoring should have | taken place at admission given that the pregnancy had been identified as high risk.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“I note that it was found that there was no nationally recognised way of flagging in maternity notes that a pregnancy is considered high-risk. As a consequence, the community midwife and GP were not aware that the pregnancy was high-risk, and additionally the mother herself was not explicitly counselled about this.”
Stated timescale: 2023/24
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2021Jos Tartese-Joy4 years 1 month after Rafe Angelo · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight a lack of cardiotocography (CTG) monitoring in maternity care settings. The earlier report notes CTG unavailability in birthing centres for emergencies, while the later report states CTG should have been performed on admission for a high‑risk pregnancy.
Rafe Angelo · 27 Nov 2017
“CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.”
Original on judiciary.uk ↗ Jos Tartese-Joy · 31 Dec 2021
“During the inquest it was accepted that CTG monitoring should have | taken place at admission given that the pregnancy had been identified as high risk.”
Original on judiciary.uk ↗
Stated action · timescale: April 2019
“the HSIB will investigate around 1,000 cases a year with the expectation that the learning from investigations will spur system improvements leading to fewer deaths and injuries in the future.”
Stated action · timescale: 2023/24
“I note that it was found that there was no nationally recognised way of flagging in maternity notes that a pregnancy is considered high-risk. As a consequence, the community midwife and GP were not aware that the pregnancy was high-risk, and additionally the mother herself was not explicitly counselled about this.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2021 | 0.83 | 0.21 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.