Molly Keen
PFD Report
Historic (No Identified Response)
Ref: 2014-0336-wp24459
Coroner's Concerns (AI summary)
Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, despite clear indications of below-normal growth, no referral for further specialist opinion or scan was made.
View full coroner's concerns
_ 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 Ic) 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 and 25"h 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 and 2 above
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 and 25"h 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 and 2 above
Sent To
- West Hertfordshire Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
16 Sep 2014
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On June 2013 commenced an investigation into the death of Molly Rae Keen a new born baby: The investigation concluded at the end of the inquest on 10hh July 2014.The conclusion of the inquest was of natural causes together with a
Circumstances of the Death
At 11.25 hours on 10h June 2013 Molly was delivered by caesarean section: She was in a very poor condition. Resuscitation was stopped at 11.54,
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation has the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.