Recurance · prevention of future deaths reports
Pre-inquest brief
Inappropriate use of intrapartum CTG guidance for antenatal monitoring
The earlier warning
Arthur Brockett-Deakins · 25 Feb 2014 · Andrew Harris, London (Inner South)
“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”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 24 Sept 2014 · Isa Mushtaq · Sara Lewis · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · 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”
Later · Isa Mushtaq · 24 Sept 2014
“Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:”
What happened next
No web check of the stated actions has been published for this chain.