1. There was not standardisation of the terminology used by the midwives and obstetricians to describe the meconium found, and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions. Sometimes grades I, II & III were used; sometimes significant & insignificant; sometimes thick or thin.

There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features.

2. The obstetric registrar attending Ziggy’s mum did not make any note in the medical records after 3.46am, even retrospectively.

3. I was told that your trust does not have a local policy regarding the use of centralised CTG monitoring, and it seems that such a policy merits consideration.

4. There is national guidance that there should be a fresh eyes review every hour for women in labour, but your trust policy indicates only every two hours. It seems that the trust policy merits reconsideration, either to amend it or to record why there is a departure from national guidance.