Mollie Dimmock
9 Nov 2021 · Coroner Crispin Butler · Buckinghamshire
The coroner's concerns
1. lack of definition of large-for-gestational-age
“NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies. Within this Guidance, whist there is reference at paragraph 1.17 to guidance in respect mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby in the Guidance. There does not appear to be any national guidance or accepted definition of large for-gestational-age such that application of the Guidance”
2. under measurement of abdominal circumference leading to under estimation of fetal weight
“[name redacted] was a large for gestation age baby. On the balance of probabilities, comparison between the 20 week and 36 week ultrasound scans demonstrate accelerated fetal growth . Retrospective review of the 36 week scan by the Health Safety Investigation Branch clinical panel considered that the abdominal circumference of [name redacted] was under measured and this led to an under estimation of her fetal weight. [name redacted]'s mother was not referred for obstetric consultation following the 36 week scan . The first”
3. lack of obstetric referral and discussion after 36 week scan
“[name redacted]'s mother was not referred for obstetric consultation following the 36 week scan . The first opportunity for an obstetric discussion with [name redacted]'s parents about the risks of delive”