Recurance · prevention of future deaths reports
Pre-inquest brief
Misinterpretation of centile chart guidance leading to delayed recognition of fe
The earlier warning
Jos Tartese-Joy · 31 Dec 2021 · Alison Mutch, Greater Manchester South
“guidance nationally was not to look at this but to look at the % weight _ change between the last weight and the new weight.”
judiciary.uk/…/jos-tartese-joy-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Jos Tartese-Joy (31 Dec 2021) · stated 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.”
What recurred
- 6 Jun 2025 · Esme Atkinson · Alison Mutch · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.