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Found 16 results
  1. Content Article
    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.
  2. Content Article
    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.
  3. Content Article
    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.
  4. News Article
    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
  5. Content Article
    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.
  6. News Article
    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
  7. News Article
    Oversight 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