PFD report

David Anthony Hulme · Prevention of Future Deaths report

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Issued 27 Jun 2022•Plymouth, Torbay and South Devon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Significant under-resourcing of the Pathology Department
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Work with Devon system partners to assess histopathology resources and explore a system solution.

    Stated by University Hospitals Plymouth NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.
  2. Action

    Recruit four funded Consultant Pathologists.

    Stated by University Hospitals Plymouth NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.
  3. Action

    Use governed outsourcing to strengthen pathology capacity.

    Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    A national shortage of suitably qualified clinical staff may prevent timely recruitment to the approved Consultant Pathologist posts.

    Stated by University Hospitals Plymouth NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Significant under-resourcing of the Pathology Department

Wider context from the report

“I am concerned that the Pathology Department remains significantly under resourced. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Work with Devon system partners to assess histopathology resources and explore a system solution.

Verbatim wording from the response

“Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.”

Source location

Response from NHS University Hospitals Plymouth
Page 2 · response
Published 23 September 2022

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

Recruit four funded Consultant Pathologists.

Verbatim wording from the response

“I can confirm that UHP have approved the funding for 4 x Consultant Pathologist posts and whilst we cannot guarantee a date that these posts will be filled, we hope to recruit into these posts as soon as possible and are in an active recruitment phase.”

Source location

Response from NHS University Hospitals Plymouth
Page 2 · response
Published 23 September 2022

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

Use governed outsourcing to strengthen pathology capacity.

Verbatim wording from the response

“Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.”

Source location

Response from NHS University Hospitals Plymouth
Page 2 · response
Published 23 September 2022

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

Work with the Pathology network to develop additional workforce resilience across Devon and Cornwall.

Verbatim wording from the response

“Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.”

Source location

Response from NHS University Hospitals Plymouth
Page 2 · response
Published 23 September 2022

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

Approve funding for four Consultant Pathologist posts.

Verbatim wording from the response

“The evidence submitted both within the RCA and via a further report, authored by the Pathology Operations Manager, confirmed that the business case to appoint further Consultants into the Pathology Department had been approved with funding allocated to this end. It was stated that the recruitment process would commence as soon as possible.”

Source location

Response from NHS University Hospitals Plymouth
Page 1 · response
Published 23 September 2022

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

A national shortage of suitably qualified clinical staff may prevent timely recruitment to the approved Consultant Pathologist posts.

Verbatim wording from the response

“I can confirm that UHP have approved the funding for 4 x Consultant Pathologist posts and whilst we cannot guarantee a date that these posts will be filled, we hope to recruit into these posts as soon as possible and are in an active recruitment phase.”

Source location

Response from NHS University Hospitals Plymouth
Page 2 · response
Published 23 September 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Review mitigating processes to reduce patient harm within the pathology system.

    Stated by University Hospitals Plymouth NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.

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

Review mitigating processes to reduce patient harm within the pathology system.

Verbatim wording from the response

“Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.”

Source location

Response from NHS University Hospitals Plymouth
Page 2 · response
Published 23 September 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026