Infant Journal
for neonatal and paediatric healthcare professionals

HSIB report highlights fetal heart rate monitoring equipment issues

The Healthcare Safety Investigation Branch (HSIB) 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.

The 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 identified were:

  • 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 is 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
  • centralised monitoring is often installed and used with no clear understanding of its purpose or clearly defined roles and responsibilities for staff using it.

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, the NHS Supply Chain has also undertaken two safety actions to help close information gaps in the procurement processes for trusts.

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The HSIB report makes recommendations on how to improve the safety of care for mothers and babies.