Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate CTG signal quality and visibility
The earlier warning
Rafe Angelo · 27 Nov 2017 · Karen Harold, Portsmouth & South East Hampshire
“Poor technical quality of the CTG readings at a crucial time especially given "this was the first trace in am emergency situation”
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
- 14 Oct 2021 · Louie Johnston · Graeme Irvine · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · 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”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.