“Foetal heart monitoring”
Dated 2 Nov 2016, from the coroner for Shropshire, Telford and Wrekin. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 28 Dec 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated2 Nov 2016
- Deadline28 Dec 2016
- Published on judiciary.uk2 Nov 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Shrewsbury and Telford Hospital NHS TrustNamed in the report as “Shrewsbury and Telford NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 28 Dec 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) Foetal heart monitoring. lvy’s foetal heart rate ought to have been monitored and was not monitored. In the second stage of Jabour the maternal heart rate was recorded on the external CTG machine for the majority of (if not all) the time when the intent was to monitor the foetal heart rate. The confounding factor was the similarity of the heart rates at the commencement of the second stage. There were opportunities and methodologies available to resolve this issue that were not taken. There was evidence of potential error of this kind in the interpretation of CTG traces being a known phenomenon. (2} Failure to follow midwifery guidelines. a. Toconfirm assessment of the CTG using the agreed assessment tool. b. The need to request an obstetric review after 1 hour of active pushing. c. The need to request an obstetric review for maternal tachycardia. (3) Episiotomy. infiltration took place which could have led to an episiotomy and delivery within 10 minutes. There was unresolved evidence as to whether an episiotomy was a planned event or a contingency which did not arise. There was though evidence that the midwife who performed the infiltration had not performed an episiotomy since qualification and wished to have support and supervision should one become necessary. Whilst such support and supervision may have been available in this case, in other this could lead to delay.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2016-0393
- Added to Minute Book
- 8 Oct 2026
- Reuse
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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