Recurance · prevention of future deaths reports
Pre-inquest brief
Inconsistent interpretation of antenatal CTG leading to delayed response
The earlier warning
Isa Mushtaq · 24 Sept 2014 · Sara Lewis, Manchester (City)
“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.”
What was promised
No published response from National Institute for Health and Care Excellence was found for the earlier reports.
What recurred
- 18 Mar 2025 · Alonzo Wood · Joanne Andrews · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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”
What happened next
No web check of the stated actions has been published for this chain.