11 Mar 2019 Ms Jennifer McKoy · Prevention of Future Deaths report Black Country
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Concerns raised 2 Inadequate audit process for monitoring non-suspicious samples by dip-sampling View source Lack of a protocol or policy for managing the anticoagulation/prophylaxis regime for community patients with identifiable risk factors for complications View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Audit non-cancerous Walsall histology cases reported over a two-month period.
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Action
Roll out modified Southampton audits covering technical and clinical quality of non-malignant cases across all sites.
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Action
Collate modified Southampton and malignant-case audit data and present findings bi-monthly to the histopathology clinical meeting.
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AI-generated summary
Ms Jennifer McKoy · 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
Ms Jennifer McKoy underwent laparoscopic cholecystectomy in August 2018 and later developed disseminated gallbladder adenocarcinoma, with a retrospective review finding that carcinoma had been present in the original histology but was not identified. She died on 17 May 2019 after developing pulmonary venous thrombo-embolism, deep phlebo-thrombosis and disseminated gallbladder adenocarcinoma. Concerns included inadequate audit of non-suspicious samples and limited evidence of a protocol for managing anticoagulation or prophylaxis for community patients with identifiable risk factors for complications.
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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. The report was sent to Black Country Pathology Services; that does not assign responsibility.
PFD Monitor interpretation Inadequate audit process for monitoring non-suspicious samples by dip-sampling
Wider context from the report “Evidence emerged during the inquest that there was an inadequate audit process in place for monitoring non-suspicious samples by way of dip-sampling .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Black Country Pathology Services; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol or policy for managing the anticoagulation/prophylaxis regime for community patients with identifiable risk factors for complications
Wider context from the report “There was limited evidence of any protocol or policy in place for managing the anticoagulation/prophylaxis regime for community patients who have identifiable risk factors for developing complications .
” 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 Audit non-cancerous Walsall histology cases reported over a two-month period.
Verbatim wording from the response “2. Audit of non-cancerous WHT cases reported over 2 month period. | No clinical relevant errors were identified. | Completed” Source location 2020-0080-Response-from-Black-County-Pathology-Services
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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 Roll out modified Southampton audits covering technical and clinical quality of non-malignant cases across all sites.
Verbatim wording from the response “To support quality assurance systems within histology, a programme of Southampton audits had been in place at RWT. The audits involved the review of both malignant and benign cases (equivalent to 2% of the workload) to assess the technical and clinical quality of the individual departments. Due to the pressures to meet cancer targets, staffing shortages and increased activity, the audit programme was not maintained. To rectify the slippage in the Southampton audit programme, the BCPS has revised the audit programme and methodology across the network to ensure the programme is achievable and provides assurances for both malignant and benign cases. The audit programme incorporates:” Source location 2020-0080-Response-from-Black-County-Pathology-Services
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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 Collate modified Southampton and malignant-case audit data and present findings bi-monthly to the histopathology clinical meeting.
Verbatim wording from the response “5. Clinical audit lead from each site collates modified Southampton and malignant case audit data and presents findings bi-monthly to the BCPS histopathology clinical meeting. | Meeting schedule in place and minutes of meetings documented. | Completed” Source location 2020-0080-Response-from-Black-County-Pathology-Services
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations