Recurring concern

Unreliable fundal-height measurement and recording

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First reported 22 Jul 2014•Latest report 24 Jul 2019

Definition

What this concern includes

Includes failures in the fundal-height measurement and recording process, including inconsistent measurements between practitioners, incomplete or missing entries, recording in unsuitable locations, and related failures that prevent reliable interpretation of fetal growth.

Not included

  • Excludes general antenatal or maternity-care deficiencies that do not specifically concern fundal-height measurement or recording.
  • Excludes failures to interpret growth charts or refer for further assessment where fundal-height information was reliably measured and recorded; those are downstream interpretation or referral concerns.
  • Excludes unrelated fetal-growth measurements, such as estimated fetal weight or ultrasound measurements, unless the assertion explicitly links them to the same fundal-height measurement and recording process.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2019

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Healthcare Safety Investigation Branch1
National Institute for Health and Care Excellence1
Stepping Hill Hospital1
West Hertfordshire Teaching Hospitals NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Xander Curran-Pass · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent fundal-height measurement and recording

    Wider context from the report

    “5.Xander had his fundal height measured by tape measure by midwives in the community. There was a significant discrepancy between the recorded measurements of two different midwives, which altered where he was on the centile chart significantly; ”

    Source location

    Xander Curran-Pass · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Buckinghamshire

    AI-generated summary

    Molly Rae Keen · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Molly Rae Keen was delivered by caesarean section on 10 June 2013 in a very poor condition, and resuscitation was stopped at 11.54 hours. The report raised concerns about inconsistent use and recording of fetal growth charts, the failure to refer for further opinion or a possible scan despite indications of below-normal growth, and a continuing lack of clarity in joint care arrangements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incomplete and inconsistent recording of fundal-height measurements

    Wider context from the report

    “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. ”

    Source location

    Molly Rae Keen · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026