Recurring concern

Unreliable biopsy documentation and reporting

First to latest report 18 Jul 2016 — 11 Feb 2025

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 1

What this concern includes

Includes failures in biopsy documentation and reporting controls, including sufficient report capacity, documented addenda, recording of procedures and outcomes, traceability, retrieval and related quality-assurance arrangements for biopsy records.

What is not included

Excludes clinical decisions about whether to perform a biopsy when the documentation and reporting process is not deficient.
Excludes delays in obtaining or performing biopsies where no biopsy documentation or reporting failure is identified.
Excludes laboratory processing, histopathology interpretation or treatment failures after biopsy information has been reliably documented and made available.
Excludes generic clinical-record deficiencies unrelated to biopsy procedures, findings, reports or outcomes.

Trends

Reports over time

Reports mentioning this concern, 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.

British Society for Haematology1

National Institute for Health and Care Excellence1

NHS England1

United Lincolnshire Teaching Hospitals NHS Trust1

Reports and published responses 2 reports

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

11 Feb2025
Cambridgeshire and Peterborough
Concerns raised1
1. Lack of a database to record Bone Marrow Aspirate and trephine biopsy procedures and outcomes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses

British Society for Haematology
NHS England
Stated actions 1
1. British Society for Haematology
  Explore developing a registry of complications to inform future guidance.
Respondent positions 2
1. NHS England
  NHS England does not consider developing a registry for bone marrow aspiration and trephine biopsy necessary at this point.
  No action considered necessary
1. NHS England
  The British Society for Haematology, as the responsible professional society, is undertaking relevant guidance and procedure-safety work.
  Redirects responsibility
AI-generated summary

Amelia Alexandra Anuszka RIDOUT · 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

Amelia Ridout, a six-year-old girl with suspected aplastic anaemia, died after a bone marrow aspirate and trephine procedure under general anaesthetic caused internal bleeding from an iliac artery injury. Despite prolonged resuscitation and emergency surgery, the bleeding could not be stopped. The concerns identified were the development and publication of national guidelines and a standard operating procedure for these procedures, including recommended methodology, and the development of a database to record procedures and outcomes.

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 database to record Bone Marrow Aspirate and trephine biopsy procedures and outcomes
Wider context from the report
“To consider the development of a data base to record these procedures and their outcomes. ”
Source location
Amelia Alexandra Anuszka RIDOUT · 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
Explore developing a registry of complications to inform future guidance.

Verbatim wording from the response
“6. Explore the possibility of developing a registry of complications to inform future guidelines.”

Source location
Response from British Society for Haematology
Page 1 · response
Published 12 February 2025
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
NHS England does not consider developing a registry for bone marrow aspiration and trephine biopsy necessary at this point.

Verbatim wording from the response
“Regarding the development of a database to record BMA and trephine biopsy procedures and their outcomes, my colleagues with responsibility for national databases and registries have considered this, together with your Report. NHS England do not consider there is a need for us to develop a registry at this point, however we will undertake to:”

Source location
Response from NHSE
Page 2 · response
Published 12 February 2025
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
The British Society for Haematology, as the responsible professional society, is undertaking relevant guidance and procedure-safety work.

Verbatim wording from the response
“We also note many of the actions being undertaken by the BSH, as the responsible professional society for the procedure, and outlined in their response to you which include improving existing consent processes, their exploration of the possibility of a registry of complications and establishing an audit process for Trusts.”

Source location
Response from NHSE
Page 2 · response
Published 12 February 2025
Open published response
18 Jul2016
South Lincolnshire
Concerns raised1
1. Inadequate space or lack of addendum provision in biopsy reporting forms
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sidney Brian Alexander · 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

Sidney Brian Alexander, who had a cardiac transplant and other medical conditions, was admitted with several months of diarrhoea and treated for a suspected Crohn’s exacerbation. He later developed respiratory distress with diffuse right-sided infiltrates and died in hospital; a concern was raised that a biopsy report could not be fully completed because there was insufficient room on the form.

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
Inadequate space or lack of addendum provision in biopsy reporting forms
Wider context from the report
“1 ████████ Consultant Gastroenterologist gave live evidence, During that evidence he conceded that he hadn't been able to fully complete a Biopsy report for Unilabs as there was insufficient room on it. Surely a form can be expanded or provision made for an addendum? ”
Source location
Sidney Brian Alexander · Prevention of Future Deaths report
Page 2 · concerns
Open source report