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Found 17 results
  1. 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
  2. News Article
    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
  3. Content Article
    On 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
  4. Content Article
    This 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.
  5. Content Article
    Getting 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.
  6. Content Article
    Find out how patient safety depends on pathologists and laboratories in a new interactive infographic from the Royal College of Pathologists.
  7. 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
  8. 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
  9. Content Article
    NHS 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.
  10. Content Article
    This 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
  11. Content Article
    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
  12. Content Article
    The Association of Anatomical Pathology Technology (AAPT) is the professional body for anatomical pathology technologists employed in hospital and public mortuaries. Here they speak to some of their members on their roles in anatomical pathology.
  13. Content Article
    In 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"."
  14. Content Article
    This NHS Improvement document provides trusts consolidating their pathology services with guidance on the clinical governance structure of the consolidated pathology network.
  15. Content Article
    This 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.
  16. Content Article
    As 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.
  17. Content Article
    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.
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