Recurance · prevention of future deaths reports
Pre-inquest brief
Absence of cardiotocography monitoring in maternity settings
The earlier warning
Rafe Angelo · 27 Nov 2017 · Karen Harold, Portsmouth & South East Hampshire
“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.”
What was promised
Stated action 1 · response to Rafe Angelo (27 Nov 2017) · stated 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.”
judiciary.uk/…/2017-0421-Response-by-Department-of-Health.pdf
What recurred
- 31 Dec 2021 · Jos Tartese-Joy · Alison Mutch · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.