Molly Keen

_ 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