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Showing results for tags 'Pathology'.
Found 22 results
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News Article
Blood test firm blamed for 'catalogue of disasters'
Patient Safety Learning posted a news article in News
An NHS provider that won a £2bn contract to deliver blood-testing services for hospitals and GPs is failing to deliver reliable results, according to medical professionals. Synnovis, a public-private partnership between the medical company Synlab and Guy's and St Thomas' and King's College hospital foundation trusts, secured the contract in 2021 to deliver pathology services for just under 200 GP surgeries across south-east London. The BBC has spoken to GPs who say incorrect and delayed blood results are a "regular concern" and that the firm's performance is causing great distress to patients. The company, which fell victim to a ransomware cyberattack in June 2024 that caused more than 1,000 NHS operations to be postponed, said the attack had "significantly reduced our capacity to process samples". Synnovis, which serves six hospitals in London, added that it had "dedicated every available resource to delivering clinically safe and largely manual interim solutions". According to more than a dozen GPs we heard from, across all of south-east London's boroughs, the severity of challenges they face under Synnovis is causing anxiety for both patients and doctors. The GPs told the BBC that the blood-test issues were leading to unnecessary hospital referrals and wasted patient appointments. In one case the BBC was told about, an elderly man who was caring for his wife with dementia needlessly spent hours in accident and emergency (A&E) due to problems with his test. One GP, who spoke to the BBC anonymously, said: "It would [previously] never cross our minds that a blood test might not be reliable. This is now an everyday concern. "The current problems with Synnovis is nothing short of a national scandal," they added. Read full story Source: BBC News, 15 April 2025 -
News Article
Huge cyber attack caused minimal patient harm, ICB claims
Patient Safety Learning posted a news article in News
A cyber attack which crippled a region’s pathology system for three months caused only five cases of “moderate” harm and no significant harm, the NHS has claimed. The Synnovis cyber attack in June left GPs across six boroughs in London unable to order blood tests, and more than 1,000 inpatient procedures were cancelled at two large hospital trusts. But South East London Integrated Care Board said this week 498 incidents linked to the attack had been assessed, and all of them were judged to have done either “no harm” or “low harm” — except for five at Guy’s and St Thomas’ hospitals, which were assessed as “moderate” harm. The NHS’s incident response process judges “moderate” harm as where a patient “did not need immediate life-saving intervention” but needed or is likely to need other follow-up care. It is also triggered by them limiting a patient’s independence for less than six months or “affect[ing] the success of treatment, but without meeting the criteria for reduced life expectancy or accelerated disability.” Read full story (paywalled) Source: HSJ, 30 October 2024 -
Content Article
The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been lost. Delays can impact treatment options and patient outcomes. Dil Rathore is a Biomedical Scientist and Pathology Innovation Lead at Leeds Teaching Hospitals NHS Trust. In this interview, he tells us about a new tracking system he’s developed to reduce the number of patient tissue samples going missing. Can you tell us more about the histopathology service you work with? Our histopathology service focuses on diagnosing diseases by examining tissue samples under a microscope. It is key in identifying conditions like cancer, infections and inflammation. Typically collected through biopsies or surgeries, samples are processed in various ways and we then assess the tissue’s cellular structure to detect abnormalities. Our findings guide clinical decisions, such as confirming cancer types, grading tumours and determining treatment options. The detailed reports produced by our service are essential in shaping patient care and are often discussed within multidisciplinary teams for comprehensive treatment planning. Are lost samples a problem? The stress and anxiety felt by patients awaiting a potential cancer diagnosis can be made much worse if they are told their sample has been misplaced or lost. Unfortunately, this ‘never event’ happens more often than is acceptable across the NHS and globally. While working in histopathology, I became interested in clinical systems, digital pathology and sample tracking systems. These systems are used by most NHS organisations, but they are prone to user error and are inherently flawed. They can only provide historical information about a sample's past, rather than its current location, which leads to uncertainty about where these precious patient samples are at any given time. Tissue blocks move constantly around the department to undergo additional processes. Dynamic movement around the department is both a necessity and also adds to the challenge of locating these samples. How does your new system work? From developing an understanding of sample tracking systems, I identified significant opportunities to enhance patient safety. Improvements were clearly necessary, but the technology to enable change still needed to be created. So, with support from the Innovation Pop-Up* I developed a new system. Our new system allows continuous, real-time tracking of the cassettes through Radio Frequency Identification (RFID) technology. Key elements It tells us the precise location of each sample and its movement through our histopathology department. Our custom tag provides the read ranges we require for the technology to work successfully in a clinical environment. Installing antennas and readers throughout the department allowed us to collect live data on the movements of our patients' samples. Our tag provides improved signal ranges, readability, and resilience of RFID technology in harsh processing conditions. How was this work resourced and developed? Thanks to seed funding provided by the Leeds Hospitals Charity, we were able to demonstrate ‘proof of concept’ with the innovation. Demonstrating the technological capabilities of the concept helped support an additional funding application to Innovate UK’s Knowledge Asset funding, which allowed us to scale the system as a minimal viable produce (MVP). Without support and funding, we wouldn’t have been able to develop the UK's first real-time histopathology sample tracking system. Were there challenges along the way? Innovating within the NHS has historically been difficult as the required infrastructure and support mechanisms have yet to be in place. Testing a new and/or unknown technology brings uncertainty and risk. Thanks to the support of Leeds Hospitals Charity, our Innovation Pop-Up team and the Pathology departments, we have begun to understand this process more robustly and agilely. This has led to the establishment of new methods for future innovation endeavours to allow more streamlined processes to test, and potentially adopt, innovations and new ideas. What’s next for this work? Although we are still testing and validating the data, we have seen some notable improvements since using the system: The RFID real-time tracking system offers never-before-seen visibility and data on our processes, ensuring samples are accounted for from collection to testing. This can reduce the risk of human error, leading to a more rapid turnaround of results and better patient outcomes. Pathologists' workflow can be streamlined as our labs can process samples and generate reports faster, thus optimising pathologist time, allowing for quicker decision-making and treatment initiation. The impact on patient care has been incredible. Diagnostic results are being delivered quickly, helping healthcare providers make prompt decisions regarding treatment plans, leading to improved patient outcomes and quicker recoveries. What advice would you give others wanting to develop innovations in the NHS? Carrying out due diligence and discovery is vital. Knowing what technology already exists and what current market offerings are available will begin to help shape innovation. Once you understand what you would like to see, explore current offerings to investigate if simple modifications could provide the solution. If this cannot be done, work in collaboration with other departments within your Trust (Scan4Safety, Clinical Engineering, etc.) to seek a solution. What’s next for this work? We will continue to collect data on the systems' performance and expand into other areas of the Trust to enhance the data. Once we have enough data, we hope to publish our findings. We are also exploring potential partnerships to help support the commercialisation of this innovation. If you are interested in RFID or RFID for Pathology Services, please contact Dil Singh Rathore ([email protected]), Pathology Technology & Innovation Lead, Leeds Teaching Hospitals NHS Trust. *a support programme at Leeds Teaching Hospitals NHS Trust for clinicians and entrepreneurs with ideas for new products and services that solve healthcare challenges. Share your insights and innovations Have you been been involved in rolling out a new way of working that has had a positive impact on patient safety? Could you share your approach and what you have learnt along the way? To find out how you can share your insights via the hub, get in touch with the editorial team at [email protected] or find out how to submit a blog here. -
Content ArticleGetting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. In England, pathology labs carry out 1.12 billion tests each year - that's roughly 20 tests per person. This report present a new framework called the 'Clean Framework' to help shape future NHS pathology services. It is designed to help pathology networks and labs widen their focus to include the pre- and post-analytical stages of the diagnostic pathway. You will need a FutureNHS account to view this report, or you can view a short video summary of the report which includes key recommendations.
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Content ArticleFind out how patient safety depends on pathologists and laboratories in a new interactive infographic from the Royal College of Pathologists.
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Content ArticleIn this opinion piece, authors highlight the growing cohort of patients who are suffering symptoms many months after their initial COVID-19 infection and the increasing demand on GP services. They also highlight a need for studies that can illuminate the underlying mechanism and for insights into the nature of this condition, how long it’s likely to go on for, what can be done about it, and through which clinical specialties. "Many estimates of long covid suggest that greater than 10% of acute cases have features that do not resolve over the subsequent months. Extrapolated to the current global burden of covid-19, this suggests potentially over five million current "long haulers"."
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Content ArticleThis NHS Improvement document provides trusts consolidating their pathology services with guidance on the clinical governance structure of the consolidated pathology network.
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Content ArticleThis investigation was prompted by evidence given to the Bristol Royal Infirmary Inquiry which spoke of the benefits of retaining hearts for the purpose of study and teaching and identified Alder Hey as holding the largest collection. Previously, the Director of the Association of Community Health Councils had expressed concerns about contraventions of the Human Tissue Act 1961 to the then Secretary of State for Health. The investigation set out to investigate the removal, retention, and disposal of human tissue and organs at Alder Hey Children’s hospital following hospital post-mortem examinations and, the extent to which the Human Tissue Act 1961 (HTA) had been complied with. It involved examination of the professional practice and management action and systems, including what information, if any, was given to the parents of deceased children relating to organ or tissue removal, retention and disposal.
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Content ArticleAs part of Patient Safety Awareness Week 2020, the Royal College of Pathologists have released three videos. In these videos, trainees discuss error scenarios and how we can foster a positive culture of learning from those mistakes. Speakers include Dr Mathew Clark, Miss Laura Whitehouse and Dr Hamed Sharaf.
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Content Article
A conversation with pathologist, Professor Peter Johnston
Claire Cox posted an article in Processes
As part of Patient Safety Awareness Week 2020, the Royal College of Pathologists speak to Professor Peter Johnston about preventing patient harm in laboratory settings. -
News Article
Faulty pathology system causes ‘significant’ issues for GPs
Patient-Safety-Learning posted a news article in News
An ongoing fault with an acute trust’s new pathology system has left GPs with ‘significant’ workload issues and ‘anxiety’ for patient safety. At the start of this month, University Hospital Southampton (UHS) trust transferred to a new pathology IT system which resulted in issues with processing blood tests and communicating results. Wessex LMCs said the trust has shown a ‘distinct lack of understanding’ of general practice, which has caused ‘large issues’ and ‘an enormous associated workload’ for GPs. GPs in the area told Pulse that there was immediately a ‘massive backlog’ from 1 July, as blood test requests were sent using the ‘old forms’ which the lab could not process quickly enough. However, one GP partner, who wished to remain anonymous, said there was ‘absolutely no communication with primary care’ to clarify that the old forms should not be used. As a result of this backlog, UHS introduced a ‘temporary measure’ which told GP practices they could only request ‘urgent blood tests’, meaning all routine blood tests were suspended. This restriction was lifted last week, and UHS has since cleared the initial backlog, however GPs told Pulse that they are still not receiving blood test results, and those they do receive are often not in the correct format. Another Southampton GP partner, who preferred to remain anonymous, said that on top of the initial backlog – caused by slow processing of old forms – there has also been a ‘significant proportion of path results that aren’t coming into GP systems’. In one surgery, around 70% of bloods requested in one week had not yet received results. The GP partner said that "results are being processed at the hospital" but GPs "can’t see them" as a result of faults with the system. She continued: "We are trying to make clinical decisions based on results and we’re not seeing them […] It’s causing a significant degree of anxiety and concern for patient safety." Read full story Source: Pulse, 23 July 2024 -
News Article
Neighbouring providers aid cyber attack victim
Patient Safety Learning posted a news article in News
Two pathology networks are coming to the aid of a neighbour, still largely paralysed following an unprecedented cyber attack on its IT system earlier this month. HSJ has learned that Australian-owned firm Health Services Laboratories, which operates mainly from two NHS trusts in north London, will take on some of the primary care tests in south-east London while the Synnovis systems, which were taken out by the attack, are down. HSL will take on work from Lambeth and Southwark boroughs, while South West London Pathology, an NHS-run consortium based at St George’s Hospital, will take on similar work for GP practices in Bexley and Bromley. SWLP was able to connect electronically to send results back to 70 surgeries in south east London within three days. HSL confirmed it had been drafted in, but it gave no information on what tests it was performing or where, or how it was assuring itself that services in north London would not suffer as a result. Read full story (paywalled) Source: HSJ, 20 June 2024 -
News Article
Cyber attack strikes multiple hospitals
Patient Safety Learning posted a news article in News
A major health system’s pathology IT has been hit by a cyber attack, HSJ understands. A letter sent by Guy’s and St Thomas’ Foundation Trust chief executive last night said his £2.5bn-turnover trust was unable to connect to the servers of Synnovis. The problem is ongoing, and several senior sources told HSJ the system had been the victim of a ransomware attack. One said gaining access to pathology results could take “weeks, not days”. As well as GSTT – the NHS’s largest provider – neighbouring King’s College Hospital FT, which runs several hospitals in the system, and is thought to be affected. Synnovis also provides pathology services for primary care across all six of south east London’s boroughs. The news would make it one of the largest critical NHS systems brought down by a cyber attack. Read full story (paywalled) Source: HSJ, 4 June 2024 -
News Article
Health officials ‘ignored evidence of non-Covid deaths’ during lockdown
Patient Safety Learning posted a news article in News
The Covid inquiry is being urged to investigate if health officials dismissed evidence of collateral deaths during lockdown after a whistleblower claimed that pathologists’ concerns were shut down. As the inquiry prepares to hold its first full public hearing this week, Prof Sebastian Lucas, who worked as a consultant pathologist at St Thomas’ Hospital in London, claimed that PHE was not interested in what he described as “collateral deaths”. Prof Lucas wrote to Prof Kevin Fenton, the director of PHE London, on behalf of the London Inner South Jurisdiction Pathology Advisory Group. He approached the agency in January 2021 as the UK entered its third lockdown, warning that collateral deaths as a result of the pandemic had not been recorded properly. The group, which was headed up by a coroner, had identified several deaths that would not have happened had the NHS been functioning as normal. This included people who did not want to bother the doctor or who took their own lives because of lockdowns. Read full story (paywalled) Source: The Telegraph, 10 June 2023 -
Content ArticleOn the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost Coroner's concerns During the course of the investigation the evidence revealed matters giving rise to concern. If the coroner is inhibited from being in a position to confirm the cause of death of a baby, there is a risk that future deaths will occur unless action is taken. Matters of Concern The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.
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Content ArticleNHS England’s report into blood culture practices outlines key improvement steps in the pre-analytical phase of the blood culture pathway. Through targeted recommendations to trust chief executives, clinical and pathology staff, we have an opportunity to improve the blood culture pathway, antimicrobial stewardship and patient outcomes from sepsis. This document sets out proposals to improve and standardise the pre-analytical phase of the blood culture pathway. It details the outputs of the antimicrobial resistance (AMR) diagnostics improvement workstream at NHS England and NHS Improvement, and examines the required changes to improve existing processes within the blood culture pathway. It concludes with a set of recommendations for best practice. NHS England and NHS Improvement make the following four recommendations for improving the blood culture pathway: Build upon existing national guidance and best practice. Implement local monitoring to identify areas for improvement. AMR to be a core part of clinical leadership and trust governance. Improve regulation and accreditation.
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Content ArticleThis report by the National Medical Examiner, Dr Alan Fletcher, summarises the progress made by medical examiner offices in 2021 and outlines areas of focus going forward. It highlights that medical examiners continued to receive positive feedback from bereaved people—many said they appreciated being given the opportunity to have a voice in the processes after a death and knowing any concerns were listened to. It includes information on: The national medical examiner system Implementation Guidance and publications Training Stakeholders Increasing the number of non-coronial deaths scrutinised Feedback received by medical examiners in England and Wales
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Content Article
RCPath - Medical examiners good practice series
Patient-Safety-Learning posted an article in Processes
This Good Practice Series published by The Royal College of Pathologists is a topical collection of focused summary documents, designed to be easily read and digested by busy front-line staff. The documents contain links to further reading, guidance and support, and cover the following topics: Supporting people of Black, Asian and minority ethnic heritage Urgent release of a body Learning disability and autism Organ and tissue donation Post-mortem examinations Child deaths Mental health and eating disorders Out-of-hours arrangements -
Content ArticleThis is the second part of webinar three in a series designed to help the NHS respond to the Covid-19 pandemic, hosted by the Faculty of Clinical Informatics. It is hosted by Sebastian Alexander, Founding Fellow of the FCI, NHS Digital, Safety, SME Apps Programme, and features presentations on the work of the National Pathology Xchange and The National Pathology Programme.
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News Article
Trust boards instructed to ‘scrutinise’ sepsis data by NHSE
Patient Safety Learning posted a news article in News
Trust boards should start scrutinising performance against new indicators set out by NHS England this month as part of a national push to iron out unwarranted variation in performance on key sepsis blood tests, according to an NHSE report. Blood cultures are the primary test for detecting blood stream infections, determining what causes them, and directing the best antimicrobial treatment to deal with them. However, it is too often seen as part of a box-ticking exercise, according to a report published by NHSE yesterday. Improving performance on this important pathway should be integrated into existing trust governance structures for sepsis, antimicrobial stewardship, and infection control “to help secure a ‘board to ward’ focus on improvement,” the report says. It says there is too much variation in how blood cultures are taken prior to analysis and sets out two targets for trusts to use to standardise their collection. The first is ensuring clinicians collect two bottles of blood, each containing at least 20ml for culturing. The more blood collected, the higher the rate of detecting bloodstream infections. Blood culture bottles “are frequently underfilled”. The second is ensuring blood cultures are loaded into an analyser as fast as possible, within a maximum of four hours, because delaying analysis reduces the volume of viable microorganisms that can be detected. Read full story (paywalled) Source: HSJ, 1 July 2022 -
News ArticleOversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found. Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses. “Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.” Read full story Source: The Washington Post, 2 June 2021
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News Article
NHS Digital receive approval for the pathology information standards
Patient-Safety-Learning posted a news article in News
In a positive step towards the future of pathology, NHS Digital has received approval from the Data Alliance Partnership Board (DAPB) for a new set of pathology information standards, and as part of NHS England CCIO7 workstreams, NHS Digital are delivering the ability to share pathology results across health and care. This move will enable clinicians to share and access critical information about pathology tests and results and receive the right information when they need it, which will help support improved clinical decision making and patient safety. Read full story. Source: Wired Gov, 19 August 2021
