Inappropriate use of intrapartum CTG guidance for antenatal monitoring
Department of Health and Social Care received 2 coroners' reports about this hazard between 25 Feb 2014 and 24 Sept 2014.
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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 7 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:”
Original on judiciary.uk ↗ Repeated from the earlier report:RelianceNICEintrapartum
The most recent report. A response may not be due or published yet.
- 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.
2014 → 2014Isa Mushtaq7 months after Arthur Brockett-Deakins · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight the inappropriate reliance on NICE intrapartum CTG guidance for situations where it is not validated. The earlier report concerns its use during labour to decide when to escalate; the later report concerns its use to interpret antenatal CTG traces.
Arthur Brockett-Deakins · 25 Feb 2014
“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”
Original on judiciary.uk ↗ Isa Mushtaq · 24 Sept 2014
“Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No published response from Department of Health and Social Care was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 |
|---|---|---|---|---|
| 2014 → 2014 | 0.73 | 0.17 | 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.