Recurring concern

Failure to reliably monitor and interpret infant growth centiles

First to latest report 22 Jul 2014 — 6 Jun 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
1

What this concern includes

Includes failures in the dedicated process for maintaining, recording, tracking and interpreting infant or fetal growth centiles, including availability of centile charts in handheld maternity records, early infant weight-centile tracking, recognition of falling trajectories and referral or further-check triggers based on growth-chart findings.

What is not included
  • Excludes general antenatal, postnatal or child-health assessment deficiencies where growth-centile monitoring or interpretation is not the unsafe condition.
  • Excludes failures involving fundal-height measurement or recording where infant or fetal growth-centile tracking is not materially involved.
  • Excludes failures to provide treatment, nutrition or feeding support after a concerning growth pattern has been reliably identified and escalated.
  • Excludes generic record-keeping, training or communication deficiencies that are not directly part of the infant-growth centile monitoring and interpretation process.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Esme Vera Louise Atkinson · 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

    Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

    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

    Failure to track infant weight centiles in the early stages

    Wider context from the report

    “7. The evidence of the paediatricians at the inquest was that tracking weight on the centile chart even from an early point assisted in understanding if there was a significant issue in relation to feeding triggering professional curiosity. However the evidence from the Health Visitor appeared to suggest that centile tracking was not seen as useful before 1 month and the red book was not used to look at weight centile tracking in the early stages. ”

    Source location

    Esme Vera Louise Atkinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Digitalise the red book and progressively add information and functionality to improve access to growth and feeding data.

    Verbatim wording from the response

    “Once feeding is established, babies should usually be weighed at around 8, 12 and 16 weeks and 1 year at the time of routine immunisations. We recognise that the red book is an important tool for tracking and sharing information between healthcare professionals, and we are digitalising the red book to improve access to this data. Over time, we will add more information and create more functionality, including AI analytics, to ensure the best care is provided for the child, including detecting any anomalies in weight gain or feeding.”

    Source location

    Response from Department of Health and Social Care
    Page 4 · response
    Published 18 June 2025

    Open published response

  2. Greater Manchester South

    AI-generated summary

    Jos Tarse-Joy · 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

    Jos Tarse-Joy was born by emergency caesarean section at 41 weeks after his high-risk pregnancy was not explicitly identified to his parents or care team, no induction had been arranged, and CTG monitoring was not used on admission. He was born in very poor condition, sustained severe brain damage following hypoxia, and died at Royal Oldham Hospital on 15 December 2020. The principal concerns included communication and documentation failures, lack of appropriate monitoring and induction planning, unclear escalation processes, and wider issues concerning maternity-service layout and national guidance.

    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

    Failure to use falling centile-chart trajectory as a trigger for further checks

    Wider context from the report

    “6. Jos's position on the centile chart had dropped in the last weeks of the pregnancy. The inquest heard that from a clinician's perspective the guidance nationally was not to look at this but to look at the % weight change between the last weight and the new weight. In hindsight the way he tracked on the centile chart appeared to reflect the challenges the placenta was under and it was unclear why the dropping picture on a centile chart was not a trigger for further checks. ”

    Source location

    Jos Tarse-Joy · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Gateshead and South Tyneside

    AI-generated summary

    ARCHIE RAY GRIEVES · 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

    Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.

    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

    Inability of nursing and medical staff to interpret Growth Charts and recognise referral triggers

    Wider context from the report

    “23.The missed opportunities in this matter would have been avoided if significant findings had been “red flagged” within mother’s records. A significant finding being something which is potentially likely to impact on the management and care of the patient at some stage during their journey and more particularly one identified as factors in the policies and practices of the Trust determined to ensure the safe care of the patient and in this case mother and baby. 24.Such red flags in this matter would and should have highlighted : a) A heightened BMI b) A Fundal height above and outwith the gestational norm 25.As an added aid to safe management and care such “red flags” should cross reference specific Policies/protocols where such issues contra- indicate certain strategies (birthing pools and increased BMI large baby) or alert for protective planning and preparation 26.The fact that the Growth Chart in this matter :- a) demonstrated the baby to be large for his gestational age and b) there was an apparent lack of understanding appreciation /conflict as to the significance of The Chart as well as c) an inability to interpret The Chart by nursing and medical staff and d) more importantly a lack of awareness that such a measure should in accordance with established Trust policy have lead to a Obstetric referral and consultation, together leads to :- ”

    Source location

    ARCHIE RAY GRIEVES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cornwall and Isles of Scilly

    AI-generated summary

    Charlie Mark Jermyn · 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

    Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

    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

    Unavailability of centile charts in handheld maternity records

    Wider context from the report

    “5. There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at risk. ”

    Source location

    Charlie Mark Jermyn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. 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

    Failure to use customised growth charts when supplied or for West Herts deliveries

    Wider context from the report

    “1a) 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. 1c) 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. ”

    Source location

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

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026