Recurring concern

Insufficient pathology capacity for timely sample analysis and reporting

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First reported 25 Jul 2018•Latest report 17 Oct 2023

Definition

What this concern includes

Includes pathology-service workforce, recruitment, retention, workload, operating-capacity and backlog deficiencies that delay clinically, coronially or forensically required sample analysis or pathology reporting.

Not included

  • Excludes delays caused solely by specimen collection, labelling, transport or test-ordering failures when pathology-service capacity is not deficient.
  • Excludes non-pathology diagnostic services, including radiology, unless the assertion explicitly concerns pathology analysis or reporting capacity.
  • Excludes isolated analytical errors, interpretation failures or equipment outages where insufficient pathology capacity or backlog is not the shared unsafe condition.
  • Excludes generic hospital or department under-resourcing where its effect on timely pathology analysis or reporting is not identified.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2018–2023

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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
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.

  1. Newcastle upon Tyne and North Tyneside

    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

    Chronic shortage of Paediatric Pathologists

    Wider context from the report

    “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK. This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled. Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work. This provides insufficient time to carry out this work in a timely fashion. There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK. ”

    Source location

    Tyler Jay Ryan · 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

    Insufficient time for timely Coronial and Forensic Paediatric Pathology work

    Wider context from the report

    “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK. This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled. Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work. This provides insufficient time to carry out this work in a timely fashion. There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK. ”

    Source location

    Tyler Jay Ryan · 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

    Make registration pathways more flexible and accessible for doctors meeting required standards to join or remain in the UK medical workforce.

    Verbatim wording from the response

    “However, we do have responsibility for the registration processes through which suitably qualified doctors obtain the legal right to practise in the UK, or (in the case of specialist registration) demonstrate that they have completed specialist training across all recognised specialties. How effective we are at managing those processes clearly does have a direct bearing on how readily the UK workforce can attract and absorb the doctors required to meet ever-increasing and more complex service needs. We’re committed, as a matter of priority, to making our registration pathways as flexible and accessible as we can for all those doctors who meet the required standards to join and remain in the UK medical workforce.”

    Source location

    Response from General Medical Council
    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

    Obtain and apply less prescriptive legislation governing evidence requirements for specialist registration applications.

    Verbatim wording from the response

    “Particularly relevant here, perhaps, is the work we’re doing to make specialist registration more accessible to those who are suitably qualified, but who have not completed an approved training course in the UK. We have long sought, and have now obtained, a change to our legislation to make it less prescriptive about the evidence requirements to support an application for specialist”

    Source location

    Response from General Medical Council
    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

    Develop and implement new pathways to the specialist register for suitably qualified doctors without UK-approved training.

    Verbatim wording from the response

    “Particularly relevant here, perhaps, is the work we’re doing to make specialist registration more accessible to those who are suitably qualified, but who have not completed an approved training course in the UK. We have long sought, and have now obtained, a change to our legislation to make it less prescriptive about the evidence requirements to support an application for specialist”

    Source location

    Response from General Medical Council
    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

    Expand facilities and staffing to provide increased capacity for both parts of the PLAB test.

    Verbatim wording from the response

    “In recent years we’ve invested in additional facilities and people to offer a record number of places in both parts of the Professional and Linguistic Assessments Board (PLAB) test, which is the means by which many international medical graduates can demonstrate their knowledge and skills for registration purposes. In 2022 over 14,000 doctors sat PLAB 1 and over 13,500 doctors sat PLAB 2, which were significant increases compared to previous years. The number of places this year is around 23,000 for PLAB 1 and 16,000 places for PLAB 2 respectively.”

    Source location

    Response from General Medical Council
    Page 2 · 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

    Streamline registration processes through programmes currently underway.

    Verbatim wording from the response

    “Beyond that, we also have number of programmes underway aimed at streamlining our registration processes. I recognise that none of this amounts to assurance about specific vacancies being filled. But I hope it shows our ongoing commitment to providing effective channels into the UK medical workforce.”

    Source location

    Response from General Medical Council
    Page 2 · 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

    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

    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

    Recruitment and retention of doctors are exclusively matters for the NHS in each UK country, outside the regulator’s direct role.

    Verbatim wording from the response

    “The GMC, as the statutory regulator for the medical profession, does not have a direct role in the recruitment or retention of doctors across any specialty in the UK. This is exclusively a matter for the NHS in each of the four UK countries. Similarly, although we have responsibility for the oversight of postgraduate medical training, we have no role in determining how many doctors are trained in any specialty or subspecialty. These numbers are set by each of the UK governments in conjunction with the NHS in each of the countries. We’re not therefore in a position to take specific action to secure numbers of doctor in this speciality, or in any others.”

    Source location

    Response from General Medical Council
    Page 1 · response
    Published 30 October 2023

    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

    UK governments and NHS bodies set the number of doctors trained in each specialty or subspecialty, not the regulator.

    Verbatim wording from the response

    “The GMC, as the statutory regulator for the medical profession, does not have a direct role in the recruitment or retention of doctors across any specialty in the UK. This is exclusively a matter for the NHS in each of the four UK countries. Similarly, although we have responsibility for the oversight of postgraduate medical training, we have no role in determining how many doctors are trained in any specialty or subspecialty. These numbers are set by each of the UK governments in conjunction with the NHS in each of the countries. We’re not therefore in a position to take specific action to secure numbers of doctor in this speciality, or in any others.”

    Source location

    Response from General Medical Council
    Page 1 · response
    Published 30 October 2023

    Open published response
  2. Manchester South

    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

    Backlogs delaying pathology sample analysis

    Wider context from the report

    “5. The Inquest heard that the delay in analysis of the sample taken was due to a backlog. The backlog was not unique to the Trust and such backlogs were prevalent across pathology departments nationally due to a local and national shortage of pathologists. ”

    Source location

    Robert Thomas Wrinch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026