Louie Johnston

1. CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery. This meant that a graphic representation of the CTG trace was not clearly visible at all times. Instead , midwifery staff were required to crouch down and record numeric data from the CTG displayed on a small LED screen. The Trust identified this as counter-productive and raised the issue with the manufacturer of the system. To date, the system has not been updated .
2. A review of staff training records indicated that an obstetric registrar involved in the delivery was not up to date with mandated annual CTG training. Additionally, the obstetric consultant had not completed annual training which required the session to be repeated following the death of Louie Johnston. Systems in place at the Trust did not ensure that all medical staff had completed requisite training .