Written evidence submitted by The Royal College of Pathologists (PSN0005)


Maternity care and leadership

Recommendation 1:

“There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and perinatal deaths, and should have raised concerns in the University Hospitals of Morecambe Bay NHS Foundation Trust before they eventually became evident. Legislative preparations have already been made to implement a system based on medical examiners, as effectively used in other countries, and pilot schemes have apparently proved effective. We cannot understand why this has not already been implemented in full, and recommend that steps are taken to do so without delay.” (From the inquiry into Morecambe Bay Investigation, 2015)

The role of medical examiners in investigating baby deaths

Medical examiners are part of a national network of specifically trained independent senior doctors (from any specialty). Overseen by a National Medical Examiner, they scrutinise all deaths that do not fall under the coroner’s jurisdiction across a local area.

Paediatric and perinatal pathology workforce concerns

The impact of perinatal pathology services

What can be done to resolve the crisis?

College response to proposals on Coronial investigation of stillbirth cases in England and Wales

About the Royal College of Pathologists

The Royal College of Pathologists is a professional membership organisation with more than 11,000 fellows, affiliates and trainees, of which 23% are based outside of the UK. We are committed to setting and maintaining professional standards and promoting excellence in the teaching and practice of pathology, for the benefit of patients.

Our members include medically and veterinary qualified pathologists and clinical scientists in
17 different specialties, including cellular pathology, haematology, clinical biochemistry,
medical microbiology and veterinary pathology.

The College works with pathologists at every stage of their career. We set curricula, organise training and run exams, publish clinical guidelines and best practice recommendations and provide continuing professional development. We engage a wide range of stakeholders to improve awareness and understanding of pathology and the
vital role it plays in everybody’s healthcare. Working with members, we run programmes to
inspire the next generation to study science and join the profession.

1.              Armstrong S. A Crisis of Pathology. Available at: https://www.prospectmagazine.co.uk/essays/52804/a-crisis-of-pathology

2.              Joint Maternity and Baby Loss All-Party Parliamentary Group. Notes of the All-Party Parliamentary Group on Baby Loss and All-Party Parliamentary Group on Maternity Joint Meeting. Available at: https://www.lullabytrust.org.uk/wp-content/uploads/Joint-Maternity-and-Baby-Loss-APPG-12-July-2022-Notes.pdf

3.              Hug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. The Lancet 398;10302:772–785. 

4.              Stenton S, McPartland J, Shukla R, Turner K, Marton T, Hargitai B et al. SARS-COV2 placentitis and pregnancy outcome: A multicentre experience during the Alpha and early Delta waves of coronavirus pandemic in England. EClinicalMedicine 2022;47:101389


Dec 2023