The investigation that underpins the report was launched after a review of maternity investigations identified common issues related to the use of cardiotograph (CTG) machines. The initial review consisted of 39 maternity investigations into intrapartum stillbirths and neonatal deaths. An examination of another 138 completed maternity investigations provided further insight with 238 findings across those reports that referenced issues with CTG monitoring in some form.
Our investigation examined the decision making process behind how the machines are purchased and how staff are trained and assessed as being ‘competent’ to use them. The main issues they identified in relation to fetal heart rate monitoring related to:
- Variation in procurement process – the investigation references the differences in the way trusts across the country handle procurement of the equipment. Examples ranged from multidisciplinary teams with relevant staff and expertise involved in the process to single clinicians purchasing incompatible equipment with no input from staff.
- Unintended Impact of national guidance - the investigation identified that some national guidance had affected procurement decision making, which is not the intent of the guidance. HSIB saw examples where this had led to new equipment not being compatible with existing equipment or not meeting the full operational needs of the trust.
- Knowledge of equipment – the investigation found that there was a lack of formal training being conducted by trusts to ensure that staff had in-depth knowledge of the equipment they were using.
The report concludes with three recommendations focused on unintended consequences from national guidance impacting on procurement of CTG equipment, and a lack of assessment of competency for staff on equipment. As a result of the investigation, NHS Supply Chain have also undertaken two safety actions. to help close information gaps in the procurement processes for trusts.
Dr Stephen Drage, Director of Investigations at HSIB says: “ Issues with fetal heart rate monitoring equipment during labour is a reoccurring theme across our maternity investigations. This national report brings together the expertise of both our investigation teams and provides a unique perspective on the equipment and technology used to interpret fetal monitoring.
Our report highlighted a variability in approach to procurement and identified that more needed to be done to ensure that training provided staff with the in-depth knowledge needed to effectively use CTG equipment. The findings and recommendations contained in the report are aimed at ensuring these issues are tackled at a national level as well as providing learning for trusts. They can use the analysis in our report to consider their own processes and where they could make changes to improve the safety of mothers and babies in their care.”
Key findings in full
- There is variation in the way trusts approach the procurement of equipment and in the use of multidisciplinary team working during the procurement process.
- There was a lack of use of change management processes by trusts to help ease new processes/equipment into service.
- Multiple manufacturers produce monitoring equipment with multiple specifications.
- There is no consistent approach to training for maternity staff on the equipment they use.
- There are no competency checks for maternity staff on the operation of CTG monitoring equipment (there are checks on their ability to analyse the output of CTG machines).
- Centralised monitoring is often installed and used with no clear understanding of its purpose or clearly defined roles and responsibilities for staff using it.
- National guidance has inadvertently influenced some trusts’ procurement decisions, which has in some cases resulted in financial cost.