Recurring concern

Insufficient pathology capacity for timely sample analysis and reporting

First to latest report 25 Jul 2018 — 17 Oct 2023

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 7

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.

What is 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.

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.

Department of Health and Social Care2

Royal College of Pathologists2

General Medical Council1

Greater Manchester Strategic Health Group1

NHS England1

Stockport NHS Foundation Trust1

Reports and published responses 2 reports

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

17 Oct2023
Newcastle upon Tyne and North Tyneside
Concerns raised2
1. Chronic shortage of Paediatric Pathologists
2. Insufficient time for timely Coronial and Forensic Paediatric Pathology work
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

General Medical Council
NHS England
Stated actions 7
1. General Medical Council
  Make registration pathways more flexible and accessible for doctors meeting required standards to join or remain in the UK medical workforce.
2. General Medical Council
  Obtain and apply less prescriptive legislation governing evidence requirements for specialist registration applications.
3. General Medical Council
  Develop and implement new pathways to the specialist register for suitably qualified doctors without UK-approved training.
1. General Medical Council
  Expand facilities and staffing to provide increased capacity for both parts of the PLAB test.
2. General Medical Council
  Streamline registration processes through programmes currently underway.
3. NHS England
  Implement recruitment incentives to attract pathologists into higher specialist training in paediatric and perinatal pathology.
4. NHS England
  Support learning through e-learning resources for paediatric and perinatal pathology.
Respondent positions 2
1. General Medical Council
  Recruitment and retention of doctors are exclusively matters for the NHS in each UK country, outside the regulator’s direct role.
  Outside remit
1. General Medical Council
  UK governments and NHS bodies set the number of doctors trained in each specialty or subspecialty, not the regulator.
  Redirects responsibility
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
25 Jul2018
Manchester South
Concerns raised1
1. Backlogs delaying pathology sample analysis
This report raised 5 other concerns. 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.
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