An obstetrician in training was the highest medical doctor during a baby delivery. During the labour of the mother, this trainee monitored the CTG to assess the condition of the unborn. A CTG is notoriously difficult to interpret. She had the impression that the baby was doing okay. As it turned out, it was not and the baby died.

Analysis of the CTG lead to the belief that it showed clear signals about the deterioration of the baby’s condition that would have warranted a direct surgical intervention by the responsible obstetrician. The opinion of the head obstetrician was that the trainee should have called him. The hospital blamed the trainee for not being able to read the CTG correctly. The trainee made a mistake, or even a judgement error because of insufficient training.

One could consider the behaviour of the head obstetrician as well as the hospital quite a lower level (e.g. level 7).