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.

• As the lead medical royal college, the College supports the view that medical examiners (MEs) should work with coroners to investigate stillbirths and neonatal deaths. This would help identify unusual patterns, such as high numbers of deaths at one hospital, which can be a strong indicator of poor care.
• The 2015 Report of the Morecambe Bay Investigation by Dr Bill Kirkup recommended that the role of medical examiners should be extended to stillbirths as well as neonatal deaths.
• We recommend that investigating stillbirths be added to the remit of medical examiners, who would then make an initial assessment of a stillbirth death in the same way that they do for adult deaths. MEs would refer only those stillbirths they think need further investigation. Coronial investigation of full-term macerated stillbirths is less likely to reveal acute failings in care than investigation of intrapartum stillbirths. However, review of antepartum stillbirths may reveal failings in wider antenatal care.
• There could be specifically trained regional MEs who could review stillbirth cases and refer those deemed appropriate for coronial investigation. However, it will be important to ensure that there are enough medical examiners in post with adequate resources to be able to take on this additional role.

Paediatric and perinatal pathology workforce concerns

• The paediatric and perinatal pathology (PPP) workforce crisis has been worsening since the early 2000s following the organ retention scandal.1 This has been made worse by the fact that pathology education in medical schools has continued to shrink over the last decade, to the point where most medical students have never been exposed to microscope and histological slides.
• Current data indicate that only 55 of the 80 full-time equivalents PPP posts in the UK are filled, leaving 25 vacancies.2 Regional disparities are evident as the workforce is concentrated in London and the North West, leaving other areas like Northern Ireland and Wales with no or a singlehanded PPP in post. There are 9 PPP trainees and 3 more are expected to join soon. However, other full-time consultants will be retiring in the coming years or have been affected by work-related stress and sickness. Brexit has also been a contributing factor, with several European consultants leaving the country after this took place and fewer being recruited from European countries..
• Therefore, to cope with any increase in demand and to ensure quality of care, a rapid and significant increase in consultant numbers would be needed. Increased numbers of consultants would be needed in several different units.
• While some trusts have managed to maintain paediatric pathology services with support from general histopathologists with interest or previous experience in paediatric pathology, the same has not happened to perinatal pathology. This key area – dedicated to the study of the fetus, neonate and placenta – has been profoundly affected by the workforce crisis. 
• Pathology trainees have a two-week exposure to perinatal pathology during their training. This short exposure, combined with the high-volume workload and limited private practice opportunities in perinatal pathology, affects speciality choices for pathologists in training.
• Recruitment and retention salary premiums may need to be paid to encourage trainees to undertake specialist training in perinatal pathology. Work life balance and opportunities for flexible working would also be valued by trainees.
• Additional training posts require funding to ensure succession planning for consultant positions.
• If coronial investigations of stillbirths were to be introduced, consideration also needs to be given to which other staff groups need to be involved in investigating and their existing capacity and workload. This would involve biomedical scientists, radiologists, anatomical pathology technologists and secretarial staff. Additional testing may also be needed by other medical specialties, such as genetics, toxicology or microbiology. Allowance would need to be made for costs to increase in line with inflation.

The impact of perinatal pathology services

• Stillbirth is regarded as a marker of the quality provided by a health system during pregnancy and delivery. Although the exact global burden of stillbirth is unknown, a recent study published in The Lancet estimated that 2 million babies were stillborn in 2019, with more occurring in sub-Saharan Africa and Southeast Asia than in the developed world.3 
• Perinatal pathology played a significant role during the COVID-19 pandemic. During the Alpha and Delta waves in 2020 and 2021, perinatal specialists realised that the placenta could be affected by COVID-19; they then described what is now known as SARS-CoV2 placentitis. The perinatal pathologists were also able to link this new disease of the placenta to the cause of placental insufficiency which, in turn, leads to miscarriages and stillbirths in many cases. Perinatal pathologists also demonstrated the occurrence of vertical transmission of SARS-CoV2 in some cases, which helped to understand the physiopathology behind COVID-19 in pregnancy.4
• The crisis in perinatal pathology is parallel to workforce problems affecting mortuary technicians with expertise in perinatal and paediatric cases. This also limits the capacity of the consultant workforce. Anatomic pathology technicians (APTs) play a key role to provide a high-quality service to patients and families. Mortuary staff receive and release bodies following Human Tissue Act requirements, helping with the evisceration at post mortem, reconstructing and preparing the body for viewing and, importantly, running the bereavement suite. 
• Families who have lost a child are always offered the option of a visit. Due to the lack of adequate workforce, many families travel long distances to the hospital where the post mortem was performed. It is the mortuary staff who receive and accommodate the family in the bereavement suite, supporting them during a very traumatic time in their lives. Importantly, the training of APTs has recently changed and to obtain this qualification they should undertake 2 years in an adult mortuary plus 1 additional year at a paediatric/perinatal mortuary, not leaving room for pure paediatric/perinatal training. This curricular change will, undoubtedly, reduce even more candidates to become paediatric/perinatal APTs. 

What can be done to resolve the crisis?

• The NHS England Specialist Services Recruitment and Workforce Strategy Group was set up to solve the crisis. However, the results will not be immediate and the short term solution should be based on international recruitment. After 2 decades since the beginning of the crisis in PPP, the increased demand has not been matched with an appropriate training and recruitment strategy. Plans such as mutual aid and outsourcing have not been able to avoid the increasing backlog, which in some non-urgent cases may be 12 months. Upskilling biomedical scientists in placenta grossing and reporting, so they can be appointed consultant healthcare scientists, will be an advantageous resource that will help shape the future of PPP services.6
• However, this can only be achieved if funding and educational support is in place to substantiate this curricular development. Investment in digital pathology and in research projects to aid the progress of artificial intelligence are part of transformation programmes, which are timely technological developments that can help transform pathology services in the NHS and beyond. 
• Unless the multiplicity of issues causing the current workforce are resolved, the paediatric and perinatal pathology service provision will deepen even more in the near future. The time to act is now.

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

• The Royal College of Pathologists responded to a consultation published on 26 March 2019 by the Ministry of Justice and Department of Health and Social Care on proposals for introducing coronial investigations of stillbirth cases in England and Wales. Our full response is published on the College website.
• The College recommends that Coroners should be adequately resourced to ensure full post mortems can be carried out.
• The activities of Coroners should also link in to the other groups who already investigate stillbirth and perinatal death.

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