Inadequate CTG signal quality and visibility
Department of Health and Social Care received 2 coroners' reports about this hazard between 27 Nov 2017 and 14 Oct 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Poor technical quality of the CTG readings at a crucial time especially given "this was the first trace in am emergency situation”
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
- 3 years 11 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery.”
Original on judiciary.uk ↗ 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.
2017 → 2021Louie Johnston3 years 11 months after Rafe Angelo · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems with the clarity and reliability of cardiotocography (CTG) monitoring during labour. The earlier report cites poor technical quality of CTG readings at a critical moment, while the later report describes equipment that forces staff to switch screens, obscuring the graphic trace.
Rafe Angelo · 27 Nov 2017
“Poor technical quality of the CTG readings at a crucial time especially given "this was the first trace in am emergency situation”
Original on judiciary.uk ↗ Louie Johnston · 14 Oct 2021
“CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery.”
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.”
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 |
|---|---|---|---|---|
| 2017 → 2021 | 0.79 | 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.