Misinterpretation of CTG traces leading to missed abnormal fetal heart rate
Royal College of Obstetricians and Gynaecologists received 3 coroners' reports about this hazard between 22 Feb 2017 and 18 Mar 2025.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ Royal College of Obstetricians and Gynaecologists responded.Response (PDF) ↗
- 2 years 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“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.”
Original on judiciary.uk ↗ Royal College of Obstetricians and Gynaecologists responded.Response (PDF) ↗
- 5 years 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“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.”
Original on judiciary.uk ↗ Royal College of Obstetricians and Gynaecologists responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“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”
- All reports to Royal College of Obstetricians and Gynaecologists
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 → 2020Harry Richford2 years 11 months after Maxim Karpovich · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in responding to abnormal cardiotocograph findings during labour. They differ in focus: the earlier stresses training deficits, while the later stresses unclear processes and delayed action.
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.”
Original on judiciary.uk ↗ 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.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“in partnership with the Royal College of Obstetricians and Gynaecologists and Health Education England e-Learning for Healthcare developed a comprehensive web-based resource called eFM: an e-learning resource aimed at improving the interpretation of electronic fetal monitoring and subsequent management. This is a free resource for all employees of the National Health Service and contains knowledge-based interactive tutorials, assessments”
2020 → 2025Alonzo Wood5 years 1 month after Harry Richford · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight unclear guidance regarding cardiotocography (CTG) interpretation and the subsequent actions required, creating a risk of delayed response.
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.”
Original on judiciary.uk ↗ Alonzo Wood · 18 Mar 2025
“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.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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”
No specific action could be extracted with a verified quote.
- 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 Royal College of Obstetricians and Gynaecologists 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 → 2020 | 0.69 | 0.10 | Closely related · 0.85 | different |
| 2020 → 2025 | 0.67 | 0.06 | 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.