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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.

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.

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.

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.