Maxim Karpovich
22 Feb 2017 · Coroner David Hinchliff · West Yorkshire (East)
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. misinterpretation of CTG traces leading to missed abnormal fetal heart rate patterns
“It was apparent that the Midwives involved with [the deceased]'s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions. The Obstetric Registrar, at 2357 hours, incorrectly classified the CTG to be normal when it clearly was not. The baby, [the deceased], who was delivered by an emergency caesarean section. Expert evidence stated that if the caesarean section had been carried out by midnight, the baby would have survived, although there could”
2. lack of core skills to interpret CTG tracings
“Midwives and Obstetricians lack the core skills to interpret CTG tracings for intrapartum care”
3. absence of quality controlled CTG training modules
“There is a need for the development of quality controlled training modules. Such courses should last for at least two days and cover the correct use of the CTG technology; foetal pathophysiology; understanding of the role of infection fever and meconium aspiration, trauma and other stresses and their interaction with asphyxia”
4. absence of mandatory competence testing for CTG interpretation
“There should be mandatory confirmation of competence at CTG interpretation with pass or fail testing before entering practice to determine the critical issues around the contents of intrapartum CTG training modules and the validity of associated tests”
5. lack of training on pattern recognition and clinical response to CTG changes
“This training should address pattern recognition, pathophysiology of foetal heart rate changes, clinical scenarios with CTG's and appropriate responses”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken.”
This report
“This training should address pattern recognition, pathophysiology of foetal heart rate changes, clinical scenarios with CTG's and appropriate responses.”
Closely relatedConfidence 0.85 · high
This report
“It was apparent that the Midwives involved with [the deceased]'s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions.”
Later report
“There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.”
Responses
Response-from-Royal-College-of-Midwives.pdf ↗· Royal College of Midwives
Stated action
“in partnership with the Royal College of Obstetricians and Gynaecologists and Health Education England e-Learning for Healthcare developed a comprehensive web-based resource called eFM: an e-learning resource aimed at improving the interpretation of electronic fetal monitoring and subsequent management. This is a free resource for all employees of the National Health Service and contains knowledge-based interactive tutorials, assessments”
Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1.pdf ↗· Royal College of Obstetricians and Gynaecologists