“4a) Buckinghamshire Healthcare NHS Trust (Bucks) employ a customised growth chart as part…”
Dated 22 Jul 2014, from the coroner for Buckinghamshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 16 Sep 2014. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated22 Jul 2014
- Deadline16 Sep 2014
- Published on judiciary.uk22 Jul 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Hertfordshire Teaching Hospitals NHS TrustNamed in the report as “West Hertfordshire Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Sep 2014. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 4a) Buckinghamshire Healthcare NHS Trust (Bucks) employ a customised growth chart as part of their ante natal care. Where ante natal care is provided in West Hertfordshire Hospitals NHS Trust (West Herts) but the birth is intended to happen at Stoke Mandeville Hospital then Bucks supply a growth chart to be kept in the mothers file and utilised. 1b) West Herts do not use customised growth charts for their own deliveries. 4c) An expert witness in midwifery opined that where a chart is supplied, it should be used. 1d) Discussions between Bucks and West Herts to improve this aspect of joint care are currently in abeyance. There is a continuing absence of clarity as to how such joint care should be delivered. 2) Midwives within West Herts estimate fetal growth by measuring fundal height. However:- a) In the immediate case, measurements were variously part recorded on the growth chart, or written on the file, or not recorded at all. As a consequence, an overall assessment of fetal growth is obscured. b) The evidence disclosed that although there was (nevertheless), clear indication that the growth of the baby was below normal expectations, no attempt was made to refer the case for further opinion, and a possible scan. 3} Further information given during the inquest did not reassure me that all necessary steps have been taken to remedy the issues outlined in 1 and 2 above.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2014-0336
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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