Recurring concern

Unreliable pathology report tracking and follow-up

Get email alerts

Request correction

First reported 25 Jul 2018•Latest report 17 Oct 2023

Definition

What this concern includes

Includes failures in the dedicated pathology-report process involving report completion or filing, tracking outstanding reports, monitoring delays, ensuring receipt by responsible clinicians and communicating reports to relevant care providers when needed for diagnosis, genetic assessment or follow-up.

Not included

Excludes non-pathology diagnostic reports, imaging reports and laboratory results unless the assertion explicitly concerns the same pathology-report process.
Excludes failures to interpret or act on a pathology report after it has been reliably received and made available to the responsible clinician.
Excludes generic clinical-record, communication or tracking deficiencies where pathology reports are not the material object.
Excludes failures in ordering or obtaining a pathology specimen when the report-tracking, completion or communication process is not deficient.

Reports: 3
Individual concerns: 6
Date range: 2018–2023
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Royal College of Pathologists2

General Medical Council1

Greater Manchester Strategic Health Group1

NHS England1

Northern Care Alliance NHS Foundation Trust1

Stockport NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

17 Oct2023
Newcastle upon Tyne and North Tyneside
Concerns raised2
1. Failure to identify the need for genetic testing before the Pathology report
2. Delays in Paediatric Pathology reports
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement recruitment incentives to attract pathologists into higher specialist training in paediatric and perinatal pathology.
  Stated by NHS EnglandStated completed
2. Action
  Support learning through e-learning resources for paediatric and perinatal pathology.
  Stated by NHS EnglandStated completed
AI-generated summary

Tyler Jay Ryan · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Tyler Jay Ryan, aged 11, was found collapsed in his bedroom on 12 February 2021 and died after resuscitation attempts. Genetic testing identified two RYR2 variants associated with CPVT, following earlier differing pathological opinions. The report raised concerns about delays in paediatric pathology reporting and the delayed identification of families who may need genetic testing, as well as the need for wider use of molecular autopsy and revision of the SUDIC Protocol.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify the need for genetic testing before the Pathology report
Wider context from the report
“2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood. Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified. Reports can take up to two years to be filed. ”
Source location
Tyler Jay Ryan · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in Paediatric Pathology reports
Wider context from the report
“2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood. Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified. Reports can take up to two years to be filed. ”
Source location
Tyler Jay Ryan · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement recruitment incentives to attract pathologists into higher specialist training in paediatric and perinatal pathology.

Verbatim wording from the response
“In your Report you raise a concern over the shortage of Paediatric Pathologists and the delays that this can cause to Paediatric Pathology reports. The shortage of paediatric and perinatal pathologists and the impact it has on services has been of concern for some time. This issue has been the subject of a great deal of activity relating to attracting pathologists into higher specialist training in this area with the implementation of recruitment incentives (one-off payments of £20,000) as well as supporting learning via e-learning resources.”

Source location
Response from NHS England
Page 1 · response
Published 30 October 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support learning through e-learning resources for paediatric and perinatal pathology.

Verbatim wording from the response
“In your Report you raise a concern over the shortage of Paediatric Pathologists and the delays that this can cause to Paediatric Pathology reports. The shortage of paediatric and perinatal pathologists and the impact it has on services has been of concern for some time. This issue has been the subject of a great deal of activity relating to attracting pathologists into higher specialist training in this area with the implementation of recruitment incentives (one-off payments of £20,000) as well as supporting learning via e-learning resources.”

Source location
Response from NHS England
Page 1 · response
Published 30 October 2023
Open published response
3 Feb2021
Manchester North
Concerns raised1
1. Failure to communicate pathology reports to general practitioners at hospital discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.
  Stated by Oldham Care OrganisationStated planned
Respondent positions 2
1. Position
  Directly communicating cancer diagnoses to GPs at discharge is not standard; supported outpatient disclosure is considered best practice.
  Stated by Oldham Care OrganisationExisting arrangements considered sufficient
1. Position
  Communicating a cancer diagnosis to the GP at discharge is not standard practice because it could disclose the diagnosis without appropriate patient support.
  Stated by Oldham Care OrganisationDisputes the concern
AI-generated summary

Mrs. Monica McCormick · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs. Monica McCormick developed a colonic perforation in October 2019 and underwent emergency surgery, after which pathology identified adenocarcinoma. The diagnosis was not communicated to her or her general practitioner until April 2020, following cancelled outpatient appointments, and the cancer had then spread to the liver and abdominal cavity. She died at home on 24 May 2020; the concerns included failures to follow up the pathology result, review medical records, communicate the diagnosis, and make an earlier referral for adjuvant chemotherapy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate pathology reports to general practitioners at hospital discharge
Wider context from the report
“2. The pathology report was not communicated to her general practitioner at the time she was discharged from hospital. ”
Source location
Mrs. Monica McCormick · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.

Verbatim wording from the response
“We apologise that the team did not check whether there had been a histopathology diagnosis at the time of discharge. We will share this PFD response at the Divisional of Surgery Governance Meeting and discuss with team members the importance of checking medical records in full when completing the Handover of Care Communication. It is important to highlight that these documents are completed throughout the patient admission to ensure a timely discharge once the patient is considered medically fit or optimised. We”

Source location
Response from Northern Care Alliance NHS Trust
Page 1 · response
Published 9 February 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Directly communicating cancer diagnoses to GPs at discharge is not standard; supported outpatient disclosure is considered best practice.

Verbatim wording from the response
“Dr Tierney has reviewed the case and confirms that the pathology report was not communicated to Mrs McCormick’s general practitioner (GP) at the time of discharge from hospital. However disclosure to GP at this time would not be standard practice. Any letter sent to the GP is also copied to the patient; this therefore would create the risk of a patient being made aware of a cancer diagnosis without appropriate support in place on receipt of the information.”

Source location
Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Communicating a cancer diagnosis to the GP at discharge is not standard practice because it could disclose the diagnosis without appropriate patient support.

Verbatim wording from the response
“████████ has reviewed the case and confirms that the pathology report was not communicated to Mrs McCormick’s general practitioner (GP) at the time of discharge from hospital. However disclosure to GP at this time would not be standard practice. Any letter sent to the GP is also copied to the patient; this therefore would create the risk of a patient being made aware of a cancer diagnosis without appropriate support in place on receipt of the information.”

Source location
Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021
Open published response
25 Jul2018
Manchester South
Concerns raised3
1. Lack of tracking of pathology samples and reports
2. Failure of departments to track outstanding pathology reports
3. Reliance on delayed paper delivery of pathology reports
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Robert Thomas Wrinch · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Robert Thomas Wrinch deteriorated with severe back pain and reduced mobility associated with an undiagnosed metastatic spinal malignancy, and developed bronchopneumonia. The report raised concerns about delays and inadequate tracking in pathology sample processing and reporting, reliance on paper reports, inconsistent departmental tracking systems, incompatible information technology systems between trusts, and pathology backlogs linked to shortages of pathologists.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of tracking of pathology samples and reports
Wider context from the report
“1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician. It was unclear if these issues are specific to the pathology department of the Trust or more widespread. ”
Source location
Robert Thomas Wrinch · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of departments to track outstanding pathology reports
Wider context from the report
“3. At the Trust, some departments such as the respiratory department had clear tracking systems to identify outstanding pathology reports. Other departments such as orthopaedics did not. As a result, clinicians could not readily identify where there was delay in receipt of information required to assess and diagnose a patient. ”
Source location
Robert Thomas Wrinch · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on delayed paper delivery of pathology reports
Wider context from the report
“2. The Trust had a system of issuing reports digitally to clinicians to speed up receipt. In addition the Inquest were told that due to preferences of clinicians paper copies were also produced and sent via internal mail to the treating clinicians. The Inquest heard that the responsible orthopaedic consultant relied on wholly on the paper system although this built in delay. ”
Source location
Robert Thomas Wrinch · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to identify the need for genetic testing before the Pathology report

Delays in Paediatric Pathology reports

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to communicate pathology reports to general practitioners at hospital discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised3

Lack of tracking of pathology samples and reports

Failure of departments to track outstanding pathology reports

Reliance on delayed paper delivery of pathology reports

Actions described in response 2

Actions described in response 1

Respondent positions 2