National Institute for Health and Care Excellence

Noted (AI summary) The MHRA reviewed the post-mortem report and the pharmacokinetics/dynamics of morphine, concluding that the case does not prompt a review of the maximum permitted dose or a need to adjust it based on body weight or co-morbidities. They emphasize the importance of careful titration and review of opioid dosing, as recommended in current treatment guidelines.

Noted (AI summary) The Department of Health acknowledges the coroner's concerns but states that NICE has the statutory function of producing clinical guidelines. NHS England will disseminate the case to NHS learning networks to minimise recurrence.

Noted (AI summary) NICE is currently updating its clinical guideline on Intrapartum Care (CG55) and the progress of the update can be monitored via their website. They will consult on the draft recommendations with stakeholders between 13th May - 24th June 2014 and the final guideline will be published in October 2014. The MHRA states that the incident was not reported to them and that the CTG model was placed on the market by Philips Healthcare and sold in the UK between 1992 and 2006. They included a Safety Notice from August 2002, warning of risks associated with the interpretation of CTG traces. The Nursing and Midwifery Council (NMC) will treat the information about one of the midwives as a new referral and investigate. A local supervisory authority (LSA) would be alerted to serious incidents of this nature via their database system and there is a link to the LSA for every maternity service in London who would provide guidance to a supervisor of midwives when a serious incident occurs. The Department of Health acknowledges the coroner's concerns and notes that NICE has responded on CTG interpretation. They explain the role of statutory supervision of midwives and state the NMC is reviewing this.