25 Jul 2018 Robert Thomas Wrinch · Prevention of Future Deaths report Manchester South
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Concerns raised 6 Incompatibility of pathology information technology systems between hospital trusts View source Lack of tracking of pathology samples and reports View source Failure of departments to track outstanding pathology reports View source Backlogs delaying pathology sample analysis View source Reliance on delayed paper delivery of pathology reports View source Failure to document conversations with other clinicians View source See 3 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Robert Thomas Wrinch · Prevention of Future Deaths report
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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.
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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 Greater Manchester Strategic Health Group; that does not assign responsibility.
PFD Monitor interpretation Incompatibility of pathology information technology systems between hospital trusts
Wider context from the report “4. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other . This meant that transfer of information between trusts to obtain a second opinion were more difficult .
” 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 Greater Manchester Strategic Health Group; that does not assign responsibility.
PFD Monitor interpretation Lack of tracking of pathology samples and reports
Wider context from the report “1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples . As a result, it was unclear when samples had been received and analysis had taken place . There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear . It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician . It was unclear if these issues are specific to the pathology department of the Trust or more widespread.
” 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 Greater Manchester Strategic Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure of departments to track outstanding pathology reports
Wider context from the report “3. At the Trust, some departments such as the respiratory department had clear tracking systems to identify outstanding pathology reports. Other departments such as orthopaedics did not . As a result, clinicians could not readily identify where there was delay in receipt of information required to assess and diagnose a patient .
” 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 Greater Manchester Strategic Health Group; that does not assign responsibility.
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.
” 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 Greater Manchester Strategic Health Group; that does not assign responsibility.
PFD Monitor interpretation Reliance on delayed paper delivery of pathology reports
Wider context from the report “2. The Trust had a system of issuing reports digitally to clinicians to speed up receipt. In addition the Inquest were told that due to preferences of clinicians paper copies were also produced and sent via internal mail to the treating clinicians . The Inquest heard that the responsible orthopaedic consultant relied on wholly on the paper system although this built in delay .
” 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 Greater Manchester Strategic Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to document conversations with other clinicians
Wider context from the report “1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events . Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician. It was unclear if these issues are specific to the pathology department of the Trust or more widespread.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations