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One delivery was fatally botched when the midwife was unable to understand a machine. Babies are at risk of dying because midwives are not being trained to use a common piece of heart monitoring equipment, a coroner has warned.
The problem was highlighted at the inquest of a baby, who died aged three days. His mother, then 19, was admitted to Pinderfields Hospital in Wakefield, West Yorkshire, for an induced labour.

The baby had been in hospital for five days when readings from the cardiotocography (CTG) machine, which monitors the foetal heartbeat and uterine contractions, should have led to the treatment being halted because Billy was suffering oxygen deficiency and excessive stress.

A newly-qualified midwife took over the birth and was unable to read the printout from the CTG machine, so increased the dosage of drugs to induce the labour.

The baby was eventually delivered in November 2013 using forceps after suffering severe brain damage. An investigation into the delivery was launched by West Yorkshire police but no criminal charges were brought.

The midwife told the inquest that she had not received appropriate training in the use of CTG machines during her midwifery course at the University of Bradford and had not completed the second part of an e-learning programme on the interpretation of the heart traces.

An expert witness told the coroner’s court that the lack of training was commonplace and students could become registered to work without this “essential training”.

A senior coroner for West Yorkshire, warned of the risk of future fatalities unless CTG interpretation was contained in all midwifery courses and students could not qualify until they had passed the assessment.
In a report to the Nursing and Midwifery Council, he said there should be annual refresher training and those midwives who failed should be banned from working.

In February the coroner wrote to medical leaders about the death of another baby, aged one day, at Leeds General Infirmary in 2015. The inquest was told that midwives and a junior obstetrician appeared not to understand the baby’s CTG trace.

The council said its current standards review would examine the coroner’s findings. It added that its pre-registration standards already required midwives to be “proficient at monitoring the condition of the mother and the foetus during labour and delivery”.

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