PFD report

Molly Rae Keen · Prevention of Future Deaths report

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Issued 22 Jul 2014•Buckinghamshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised4

  1. Lack of clarity in the delivery of joint antenatal care
  2. Failure to use customised growth charts when supplied or for West Herts deliveries
    Part of recurring concern: Failure to reliably monitor and interpret infant growth centiles
  3. Failure to refer cases for further assessment when fetal growth is below normal expectations
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clarity in the delivery of joint antenatal care

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor and interpret infant growth centiles.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to refer cases for further assessment when fetal growth is below normal expectations

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Unreliable fundal-height measurement and recording.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026