2 Apr 2024 Alan Andrew SOANE · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to take national action to address the Consultant Histopathologist shortage View source Failure to provide a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Increase domestic medical school places in England to expand the future pool of histopathologists and other specialists.
View source
Department of Health and Social Care
Continue working with NHS England and system partners to deliver the Long Term Workforce Plan’s workforce ambitions for patient safety and outcomes.
View source
NHS England
Expand domestic education, training and recruitment to address anticipated NHS staffing shortfalls.
View source
NHS England
Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.
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AI-generated summary
Alan Andrew SOANE · 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
Alan Andrew Soane underwent a Whipple’s procedure after an incorrect diagnosis of duodenal cancer and died on 26 June 2023 from known complications of the procedure. The report raises concerns about the absence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings and the wider national shortage of Consultant Histopathologists, which was acknowledged as contributing to the incorrect diagnosis.
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× 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 take national action to address the Consultant Histopathologist shortage
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally .
” Source location Alan Andrew SOANE · Prevention of Future Deaths report
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 to provide a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings . It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally.
” Source location Alan Andrew SOANE · Prevention of Future Deaths report
Open source report
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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 Increase domestic medical school places in England to expand the future pool of histopathologists and other specialists.
Verbatim wording from the response “The LTWP sets out the aim to double the number of medical school places in England to 15,000 places a year by 2031/32, and to work towards this expansion by increasing places by a third, to 10,000 a year, by 2028/29. We have brought forward the trajectory of this planned expansion for the last 2 years, having allocated 205 and 350 additional places for the 2024/25 and 2025/26 academic years respectively. There are now an additional 1,500 medical school places per year for domestic students in England – a 25% increase, taking the total number of medical school places in England to 7,500 each year. These expansions will increase the pool from which future histopathologists and other specialists can be drawn.” Source location Response from Department of Health and Social Care
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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 Continue working with NHS England and system partners to deliver the Long Term Workforce Plan’s workforce ambitions for patient safety and outcomes.
Verbatim wording from the response “The NHS Long Term Workforce Plan (LTWP), published by NHS England in June 2023, sets out the steps the NHS and its partners need to take to deliver an NHS workforce that meets the changing needs of the population over the next 15 years. The plan outlines the action needed to ensure we train and retain more staff, and reform medical education and training to put the NHS workforce on a sustainable footing for the future.” Source location Response from Department of Health and Social Care
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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 domestic education, training and recruitment to address anticipated NHS staffing shortfalls.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
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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 Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
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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 should further address concerns about consultant histopathologist attendance at meetings and national vacancies.
Verbatim wording from the response “In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). I have been informed that NHSE has been granted an extension to 18 June to send a response to you. As an Executive Agency of the Department of Health and Social Care, NHSE’s response should further address the concern you raised.” Source location Response from Department of Health and Social Care
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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 Trusts, rather than NHS England, are responsible for ensuring safe staffing levels in hospitals’ current day-to-day operations.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
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27 Mar 2018 Matthew Gayle · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Insufficient availability and capacity of consultant histopathologists to carry out coroners’ autopsies View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Matthew Gayle · 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
Matthew Gayle, a serving prisoner at HMP Oakwood, was found dead in his cell on 8 December 2016. The precise cause of death could not be determined, although it was considered likely to have been naturally occurring. The report raised concerns that histology had not been carried out during the post-mortem and about the availability, training, appointment, contractual arrangements and fees of consultant histopathologists undertaking coroners’ autopsies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability and capacity of consultant histopathologists to carry out coroners’ autopsies
Wider context from the report “Histopathology is very important for determining causes of deaths and it can play a significant role in preventing deaths in the future. When Matthew was found dead he had some illicit drug paraphernalia in one of his hands. He was a young man and the immediate suspicion was that this was a drug related death. The pathologist who conducted the autopsy examined Matthew’s body and took samples for toxicology. Toxicology was carefully carried out (including checking for new psychoactive substances) and the result was that there was nothing in Matthew’s system likely to have caused his death. No histology had been carried out because it was anticipated that toxicology would provide answers. Possibly if histology had been carried out it may have produced a more accurate cause of death for Matthew.
I would make it clear that I do not seek to criticise the pathologist in this respect. You will be aware that there are a declining number of consultant histopathologists who are prepared to carry out autopsies for Coroners and many of those who still perform that function are working under substantial pressure . It is important for the proper investigation of death and the prevention of future deaths that there are sufficient histopathologists to carry out autopsies for Coroner when these are required . I would greatly appreciate your assistance with the following:
1. Are active steps being taken to increase the number of consultant histopathologists who will carry out autopsies for Coroners?
2. Will it be a compulsory part of training of doctors who wish to become histopathologists that they do have experience in Coroners’ autopsies?
3. When engaging consultant histopathologists will NHS Trusts appoint doctors who are both competent and willing to carry out autopsies for Coroners?
4. When appointing consultant histopathologists will NHS Trusts ensure that their contractual arrangements enable them to have time to carry out Coroners’ autopsies?
5. Is there any move to increase the fees payable to consultant histopathologists for carrying out Coroners’ autopsies?
6. Are any steps being taken to progress the Hutton report in establishing specialist centres for histopathology?
7. Are you able to provide me with details of any consultant histopathologists who are prepared to carry out autopsies in the large geographical area that I cover?
” Source location Matthew Gayle · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.