Recurring concern

Failure to reliably arrange and complete clinically required biopsies

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First reported 28 Feb 2014•Latest report 23 Dec 2024

Definition

What this concern includes

Includes failures in the dedicated biopsy process that delay or prevent a clinically required biopsy, including identifying the appropriate specialist or service, referral and coordination, procedural protocols, scheduling, access to required expertise and timely completion.

Not included

Excludes failures in interpreting or acting on biopsy results after the biopsy has been completed, unless the same assertion also identifies a deficient biopsy-arrangement process.
Excludes generic diagnostic, staffing, communication or documentation deficiencies unless they directly impair arranging or completing a clinically required biopsy.
Excludes non-biopsy investigations and procedures, including generic clinical assessments, unless the assertion explicitly concerns the biopsy process.
Excludes delays belonging to a more specific named disease or cancer pathway when that pathway, rather than biopsy provision, is the supported unsafe condition.

Reports: 3
Individual concerns: 3
Date range: 2014–2024
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.

County Durham and Darlington NHS Foundation Trust1

Department of Health and Social Care1

Mid and South Essex NHS Foundation Trust1

National Institute for Health and Care Excellence1

University Hospitals Birmingham 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.

23 Dec2024
Essex
Concerns raised1
1. Delays in taking first biopsies
This report raised 12 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
  Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
AI-generated summary

William Charles Hare (Bill) · 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

William Charles Hare (Bill) presented with abdominal and left loin pain in November 2022 and was subsequently diagnosed with metastatic urothelial cancer. He died in a hospice on 23 January 2024 after delays in diagnosis and treatment, including delays in biopsy, specialist review, MDT consideration, hospital transfer and scan results. The report identified systemic and procedural errors and ineffective coordination between Basildon and Southend Hospitals as substantive concerns.

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
Delays in taking first biopsies
Wider context from the report
“ii. There was a delay in the first biopsy being taken which ultimately took place well outside the national guideline of 31 days. ”
Source location
William Charles Hare (Bill) · 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
Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.

Verbatim wording from the response
“We now have one comprehensive patient tracking system for all hospital sites providing a centralised monitoring for all cancer patients and their progress through the cancer pathway.”

Source location
Response from Mid and South Essex NHS Foundation Trust
Page 2 · response
Published 6 January 2025
Open published response
15 Nov2024
Birmingham and Solihull
Concerns raised1
1. Lack of a protocol identifying the correct specialism for the biopsy procedure
This report raised 1 other concern. 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
  Clarify the pathway and contact process for requesting deep tissue biopsies from Interventional Radiology.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Write supplementary multidisciplinary guidance covering treatment goals, Infection Service involvement, Interventional Radiology biopsy requests, and the distinction between sharp debridement and deep tissue biopsy.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
AI-generated summary

Rachel Alicia Elizabeth 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

Rachel Alicia Elizabeth RYAN was treated for a sacral pressure ulcer that became infected and developed into osteomyelitis, alongside deep vein thrombosis and pulmonary embolism. She deteriorated and died on 21 June 2024; the stated medical cause of death was osteomyelitis due to an infected sacral pressure sore, with frailty of old age also recorded. The principal concern was delay and lack of collaboration between specialist teams in arranging a deep tissue biopsy to guide antibiotic treatment.

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 a protocol identifying the correct specialism for the biopsy procedure
Wider context from the report
“1. On 23rd April Miss Ryan’s treating consultant geriatrician received advice from the infectious diseases team that a deep tissue biopsy was strongly recommended to best guide the antibiotic therapy for her infection. 2. Despite him liaising with/going back and forth between the Tissue Viability Nurse service, the Trauma and Orthopaedic team and the Plastic Surgery team (based at the Queen Elizabeth Hospital) between 23rd April and 1st May, none of these teams could, for different reasons, facilitate this procedure. As a result, it was not until 2nd May that assistance was sought from the interventional radiology team who agreed to help. 3. The procedure was initially due to take place on 7th May but had to be put off due to Miss Ryan being on warfarin and there were then further delays due to non-availability of the relevant specialist as well as the need to stop her existing antibiotics for 24 to 48 hours before the procedure. It was finally carried out on 21st May. 4. On 22nd May a new anti-biotic regime was commenced with it being noted that one of the bacterial organisms identified from the biopsy, namely Morganella morganii, was resistant to co-amoxicalve, the antibiotic which Miss Ryan had most recently been receiving from 15th April until 19th May. 5. Although I heard evidence that the delay in starting the new antibiotic regime was unlikely to have altered the sad outcome in this case in part due to Miss Ryan’s existing frailty and poor prognosis, I am concerned that in the absence of any existing protocol regarding the correct specialism for the biopsy procedure, no Multi-disciplinary meeting bringing together specialists from the different disciplines was offered or held in this case to agree the best way forward. This led to a delay and a lack of collaboration between teams which could, if repeated, result in an avoidable death. ”
Source location
Rachel Alicia Elizabeth 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
Clarify the pathway and contact process for requesting deep tissue biopsies from Interventional Radiology.

Verbatim wording from the response
“• The pathway and means of contacting Interventional Radiology for deep tissue biopsies has been clarified by the department.”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 3 · response
Published 19 November 2024
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
Write supplementary multidisciplinary guidance covering treatment goals, Infection Service involvement, Interventional Radiology biopsy requests, and the distinction between sharp debridement and deep tissue biopsy.

Verbatim wording from the response
“• Appendiceal guidance to supplement the existing Trust guidelines will be written by the Infection Service, Healthcare of Older Adults, Tissue Viability and Interventional Radiology. A draft should be complete by February 2025. This will include the following points:”

Source location
Response from University Hospitals Birmingham NHS Foundation Trust
Page 3 · response
Published 19 November 2024
Open published response
28 Feb2014
County Durham and Darlington
Concerns raised1
1. Failure to undertake rectal biopsy for diagnosis of Hirschsprung’s disease
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The patient did not meet NICE criteria for rectal biopsy, so the absence of a biopsy did not indicate a departure from applicable guidance.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Nathan Douthwaite · 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

Nathan Douthwaite had a long history of severe constipation requiring repeated hospital admissions and died after emergency admission in December 2010. Autopsy found massive megacolon with abdominal compartment syndrome and a perforated caecum, with Hirschsprung’s disease recorded as an underlying cause. The report raised concerns that a rectal biopsy might have diagnosed Hirschsprung’s disease and identified a need to review relevant guidelines and clinical practices.

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 undertake rectal biopsy for diagnosis of Hirschsprung’s disease
Wider context from the report
“It is likely that if Nathan had undergone a rectal biopsy, Hirschsprung’s disease would have been diagnosed with the opportunity then being available for the appropriate treatment and thus I consider (1) That NICE undertake a review of its guidelines in this regard (2) That Count Durham and Darlington NHS Trust does review its own practices and procedures in avoidance of a NICE review and (3) The Department of Health be aware of the circumstances of this case so that it can consider whether guidance should be issued in this regard pending the NICE review. ”
Source location
Nathan Douthwaite · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
The patient did not meet NICE criteria for rectal biopsy, so the absence of a biopsy did not indicate a departure from applicable guidance.

Verbatim wording from the response
“method of diagnosis for Hirschsprung’s disease. No rectal biopsy was ever performed on Mr Douthwaite as he did not meet the criteria for Hirschsprung’s. Even under NICE’s guidelines on constipation, published in May 2010, Mr Douthwaite’s condition did not meet the criteria for rectal biopsy.”

Source location
2014-0084-Response-by-Department-of-Health
Page 2 · response
Published 28 February 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in taking first biopsies

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

Concerns raised1

Lack of a protocol identifying the correct specialism for the biopsy procedure

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 undertake rectal biopsy for diagnosis of Hirschsprung’s disease

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Actions described in response 2

Respondent positions 1