Dear Mr Hinchcliff Your ref: DH/ST/893/15 re Baby Karpovich DH/KLA/3156/13 re Billy Wilson Thank vou for writing to me on 22 February and & March 2017 regarding the inquest of the deaths of Maxim Karpovich and Billy Wilson_ responded t on 17 March 2017 after meeting discussing with the RCOG Officers and seeking input and advice from the new Vice Presidents of Education and Clinical Quality: apologised to_ ifor the delay in my response explaining that needed to consult with the Curriculum Review team in some detail before address his concerns appropriately: The consensus from the RCOG Officers and the Curriculum Review team was that a theoretical course in itself _ particularly a course taking place over many weeks a5 was suggested ~was unrealistic for ail trainees, many of whom are struggling to obtain study leave from their Trusts and are also complaining bitterly about the mandatory training modules that they are expected to complete: There is also the question of whether a course is the most appropriate method of training as the problems that can arise in clinical practice are generally when the whole picture is not considered and the issue is not escalated appropriately: Cardiotocograph (CTG) training Is part of the current RCOG curriculum: In summary it is part of module 10 'Management of labour' and by the end of Specialist Training year 1 (ST1), all trainees must produce evidence of having completed a course demonstrating CTG interpretation skills (see Module 10 attached with relevant sections highlighted) before they can progress to become an ST2_ As you will see this is usually an e-learning course and the resources which most trainees use are either the KZMS" PTP (Perinatal Training Program) package or the e-learing for Healthcare Electronic Fetal Monitoring chapter: You may be aware that the K2 training requires hospitals to have a site licence and trainees can then be registered: The e-learning for Healthcare requires doctors to have a NHS email address and then they can register for free; but this precludes those working out with the NHS. However should mention here that, as the official host, the RCOG has put a significant amount of resource into supporting the eFM package, working with the Roval College of Midwives and Health Education England. Royal of Obstetricians and Gynaecologists 27 Sussex Place; Regents Park London NWI 4RG Telephone: +44 (0J20 7772 6200 Facsimile: +44 (0)20 7723 0575 Website: wwwrcogorguk Registered chanty no, 2/3280 May ` and could being College "

Royal College of Obstetricians & Gynaecologists CTG training is additionally included in the basic practical skills course which all trainees have to take to progress to ST3. One ofthe 10 practical stations is on interpretation of CTG and fetal blood sampling: All delegates are expected to complete the on-line tutorials in electronic fetal monitoring and fetal blood sampling during the pre-course preparation and should basic understanding the fetal monitoring principles_ In terms of the new curriculum; the pressure of completing modules does not allow us to increase the emphasis on CTG interpretation but it will remain an important that trainees evidence this skill; The RCOG opinion on CTG interpretation is that the problems arise in clinical practice when the whole picture is not considered, and this is why trainees are encouraged to demonstrate clinical competence within teams as part of workplace based assessments. In addition senior trainees who are likely to be in of such teams can register for our Advanced Training Skills Module (ATSM) in advanced antenatal practice or advanced labour ward practice, both of which contain curricula that deliver additional training in the teamwork around CTG interpretation which includes the running of team meetings and reviews of decision making Further details of our ATSM programme can be found at https LLWWW rcg org uklen/careers-training/specialty-training-curriculumlatsmsl: Whilst we fully understand the concerns around this case we would like to reassure you that the College is committed to ensure that safety is at the heart of anything we do. We have discussed whether one additional course such as that proposed by Professor Steer for all our trainees would enhance safety We believe that it would not and that we should therefore concentrate on ensuring consistency of our curriculum and also engaging with NHS England and the 'Safer Maternity Care' programme; launched by Jeremy Hunt at the RCOG in October 2016. This important national programme has come with a very strong bias towards team work and leadership, supported by a new funding stream for multi-professional training programmes. As am sure you are aware; the Secretary of State announced E8m of funding for maternity safety training last Autumn 2016, with at least E4Ok to each NHS Trust In England: This has allowed some units to fund training in subjects such as team working in intrapartum care and CTG interpretation via courses that have already been established: Lastly should mention that in my reply tol reminded him that the RCOG currently offer an "intrapartum fetal surveillance course" which is run over one at the RCOG and is aimed at obstetric team working: suggested to that he could Iiaise with our Convenor of Meetings to help us design a pilot programme alng the lines that Professor Steer proposes, that have charge fully day -

Royal College of Obstetricians & Gynaecologists could then be trialled at the RCOG: offered to give this my full support if he wished to pursue the proposal and believe that he has already started to do so Ifyou would like to discuss this further with me please do not hesitate to contact me

Dear Mr Hinchliff; Thank you for your letter of 23 February 2017,and do apologise for the in replying: The Royal College of Midwives is the professional organisation and trade union dedicated to serving midwifery and the whole midwifery team_ We provide workplace advice and support, professional and clinical guidance and information, and learning opportunities with our broad range of events, conferences and online resources: It is important to note that midwives are specialists In normal pregnancy and birth, and their role is to look after a pregnant woman and her baby throughout the antenatal period, labour and birth, and after the baby has been born. Where anomalies occur, midwives support their medical colleagues in providing care The Nursing and Midwifery Council (NMC) Code Professional Standards of Practice and Behaviour for Nurses and Midwives requires practitioners to maintain the knowledge and skills needed for safe and effective practice ad to recognise the limits of their competence: Point 8 of the NMC Code requires that registrants respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate and work with colleagues to preserve the safety of those receiving care: The NMC Midwives Rules and Standards 2012, Rule 5 Scope of Practice was in place at the time of Maxim's birth: The rule stated: 'In an emergency, or where a deviation from the norm, which is outside of your current scope of practice, becomes apparent in a woman or 1 0 APR 2017 cl delay during

baby during childbirth, You must call such health or social care professionals as may reasonably be expected to have the necessary skills and experience to assist you in the provision of care' A midwife was therefore required to refer to an obstetrician when abnormal findings were detected. Midwives are expected to work in accordance with their employer's guidelines ad national best practice, for example National Institute for Health and Care Excellence (NICE) guidance Fetal Heart Rate Monitoring All NHS trusts will have an evidenced-based guideline or policy on fetal monitoring: The national guidance for fetal heart rate monitoring in labour is NICE guidance Intrapartum care for healthy women and babies Clinical guideline [CG190] Published date: December 2014 Last updated: November 2016. NHS Trust's mandatory training programmes include interpretation of the fetal heart rate. Trusts also run multidisciplinary practical 'skills and drills' where the maternity team work together to identifvy and manage obstetric emergencies, which may include CTG interpretation. The RCM in partnership with the Royal College of Obstetricians and Gynaecologists ad Health Education England e-Learning for Healthcare developed a comprehensive web-based resource called eFM: an e-learning resource aimed at improving the interpretation of electronic fetal monitoring and subsequent management: This is a resource for all emplovees of the National Health Service and contains knowledge-based interactive tutorials, assessments and case studies: The RCM also offers multidisciplinary leadership courses for labour ward coordinators and obstetric clinical leads. Evidence What have, demonstrated said up to this point is that there is an awful lot of work going on to improve the ability of midwives to interpret CTGs and to improve CTG interpretation more generally however it is important to also understand that the evidence as to how far this will get us is equivocal for example: When preparing the electronic programme eFM, clinical experts were asked to provide sample CTG case studies for interpretation. Agreement was reached on only 60% of interpretations with variability between practitioners and also over time. Evidence demonstrates that CTG will not, in itself; prevent fetal loss; A 2013 meta-analysis of controlled trials of electronic FHR monitoring versus intermittent auscultation showed that the former vielded no significant improvement in overall perinatal death or Cerebral Palsy rates but was associated with a significant increase in caesarean deliveries (RR 1.63,95% Cl 1.29-2.07,N = 18,861, 11 trials). free hope,

In a recent unmasked randomised controlled trial" found that the use of computerised interpretation of CTS in women who have continuous electronic fetal monitoring in labour does not improve clinical outcomes for mothers or babies Women were randomly assigned to decision support with the INFANT decision- support software system or no decision support via a computer-generated stratified block randomisation schedule: Between Jan 6, 2010,and Aug 31, 2013,47 062 women were randomly assigned (23 515 in the decision-support group and 23 547 in the no-decision-support group) and 46 042 were analysed (22 987 in the decision - support group and 23 055 in the no-decision-support group): There was no difference in the incidence of poor neonatal outcome between the groups-172 (0.7%) babies in the decision-support group compared with 171 (07%) babies in the no-decision-support group (adjusted risk ratio 1-01, 95% CI 0.82-1*25). At 2 years, no significant differences were noted in terms of developmental assessment; do hope this information is helpful but please do contact me ifyou require any further information.