Misinterpretation of centile chart guidance leading to delayed recognition of fe
Department of Health and Social Care received 2 coroners' reports about this hazard between 31 Dec 2021 and 6 Jun 2025.
They came from 1 coroner in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“guidance nationally was not to look at this but to look at the % weight _ change between the last weight and the new weight.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“I note that it was found that there was no nationally recognised way of flagging in maternity notes that a pregnancy is considered high-risk. As a consequence, the community midwife and GP were not aware that the pregnancy was high-risk, and additionally the mother herself was not explicitly counselled about this.”
Stated timescale: 2023/24
- 3 years 5 months laterClosely relatedConfidence 0.80 · moderate
“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.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2025Esme Atkinson3 years 5 months after Jos Tartese-Joy · same coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern the use of infant weight monitoring via centile charts and the interpretation of weight changes.
Jos Tartese-Joy · 31 Dec 2021
“guidance nationally was not to look at this but to look at the % weight _ change between the last weight and the new weight.”
Original on judiciary.uk ↗ Esme Atkinson · 6 Jun 2025
“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.”
Original on judiciary.uk ↗
Stated action · timescale: 2023/24
“I note that it was found that there was no nationally recognised way of flagging in maternity notes that a pregnancy is considered high-risk. As a consequence, the community midwife and GP were not aware that the pregnancy was high-risk, and additionally the mother herself was not explicitly counselled about this.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2025 | 0.77 | 0.30 | Closely related · 0.80 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.