Recurring concern

Failure to reliably arrange and complete clinically required biopsies

First to latest report 28 Feb 2014 — 23 Dec 2024

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
3

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.

What is 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 and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    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

  2. Birmingham and Solihull

    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

  3. County Durham and Darlington

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026