Inconsistent interpretation of antenatal CTG leading to delayed response
National Institute for Health and Care Excellence received 2 coroners' reports about this hazard between 24 Sept 2014 and 18 Mar 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from National Institute for Health and Care Excellence was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ No published response from National Institute for Health and Care Excellence was found for this report.
- 10 years 6 months laterIdentical hazardConfidence 0.90 · higha different coroner
“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 ↗ National Institute for Health and Care Excellence responded.Response (PDF) ↗
- All reports to National Institute for Health and Care Excellence
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.
2014 → 2025Alonzo Wood10 years 6 months after Isa Mushtaq · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of clear national guidance on how to respond to abnormal antenatal cardiotocography findings. This leads to reliance on individual clinician judgement regarding the need and timing of delivery.
Isa Mushtaq · 24 Sept 2014
“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.”
Original on judiciary.uk ↗ Alonzo Wood · 18 Mar 2025
“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 published response from National Institute for Health and Care Excellence was found for this report.
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 National Institute for Health and Care Excellence 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 |
|---|---|---|---|---|
| 2014 → 2025 | 0.78 | 0.28 | Identical · 0.90 | 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.