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Baby safety at risk due to lack of basic training on CTGs

The cardiotocography machine (‘CTG’) monitors fetal well-being and uterine contractions, and failure to correctly interpret and act on the CTG is often a central feature of medical negligence claims involving child brain injury.

As long ago as 2012 the NHSLA report ‘Ten Years of Maternity Claims’ indicated that resources should be focused on preventing incidents associated with the management of labour, which would include those cases which centre on the interpretation of CTG traces and the timing of a caesarean section, and made recommendations for improving safety in maternity care such as compulsory attendance at regular training sessions, especially for CTG interpretation.

Despite this there is evidence that CTG training is still lacking.

In March 2017, following an inquest touching the death of baby Billy Wilson, HM Coroner David Hinchliff raised concerns about the standard of training of midwives, particularly the inability of a newly qualified midwife caring for Billy’s mother to interpret the CTG.

Having heard evidence from an expert midwife that midwives can successfully qualify without this essential training he made a Prevention of Future Deaths report to the Nursing and Midwifery Council (‘NMC’)

This report to the NMC follows an earlier report by the same Coroner directed to the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives raising concerns about the inability of a junior obstetrician and midwife to properly interpret a baby’s CTG trace.

This apparent lack of training should be one of genuine concern for those involved in promoting patient safety, a matter which the excellent mother and baby charity Baby Lifeline actively seeks to address.