Recipient

Black Country Pathology Services

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First report 11 Mar 2019•Latest report 11 Mar 2019

Recipient record

Reports, concerns and published responses

Other public bodies · Sub-organisation. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
10

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found
10stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Black Country Pathology Services linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Black Country

    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.

    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. 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

    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
    Page 3 · response
    Published 16 April 2020

    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

    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
    Page 2 · response
    Published 16 April 2020

    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

    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
    Page 3 · response
    Published 16 April 2020

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
60%30%10%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026