news focus: A shortage of paediatric pathologists is leaving a beleaguered workforce struggling to maintain a basic service.And child health services as a whole are beginning to feel the impact, as Daloni Carlisle reports

Published: 18/04/2002, Volume II2, No. 5801 Page 16 17

No best-selling author has written a blockbuster about them and they rarely feature in the television medical soaps.

The only thing the public hears about paediatric pathologists is that they are storing bits of dead babies in jam jars in the garage.

No wonder There is a staffing crisis in the specialty.

Across the UK, paediatric pathologists are struggling to maintain a basic service. A chronic lack of entrants to the specialty, coupled with the aftermath of the Alder Hey organ retention scandal, is pushing the service to the brink.

In January, the Royal Hospitals in Belfast suspended routine paediatric post-mortems. 'It is due to a shortage of paediatric pathologists and to the additional workload following the Alder Hey inquiry, ' says a spokesperson. 'We do not know when we will be able to resume normal services.'

The situation is similar in London, where fewer than five consultant paediatric pathologists carry out perinatal postmortems.

Neil McIntosh, professor of child life and health at Edinburgh University, and chair of a working group that produced a report on the future of paediatric pathology last month, says these are not isolated cases. 'Belfast has come clean about its crisis, but the situation in London, Sheffield and Bristol is very serious, ' he says. 'I know of one case in London where an obstetrician waited a month for a post-mortem he felt was vital, and That is appalling for the parents.'

According to the working party's report, there are 10 consultant posts vacant nationally - 19 per cent of the total. Of the 42 consultants in post, seven are single-handed, ten part-time and five due to retire in the next five years.

The picture is even bleaker when it comes to training positions.

Four out of nine funded training posts in paediatric pathology are unfilled. At least four more have been withdrawn in the last decade.

As the report puts it, 'It is self evident that the current number of trainees is insufficient to meet existing and future requirements.'

There are many reasons for this state of affairs, some of them long-term, such as lack of strategic planning. But the situation has been made worse by the ripple effects of Alder Hey.

Following the Redfern inquiry into organ retention at the Royal Liverpool Children's Hospital (Alder Hey) in 2000 and the Kennedy inquiry into the Bristol Royal Infirmary in 2001, all trusts have had to look in detail at what human remains they hold.

In January 2001 the Department of Health set up the Retained Organs Commission to oversee return of organs and recommend changes to legislation and practice.

This has created a 'phenomenal' amount of work, says Professor McIntosh. 'Every department has had to account for every slide, every tissue block and every organ that they have ever taken. They have had to identify who it came from and notify the family about what they want done.'

A spokesperson for the Royal Hospitals in Belfast says: 'We had to hold our own human organs inquiry. We had records going back 50 years. Paediatric pathologists have had to attend the inquiry to give evidence, had to tackle questions from Department of Health, and respond to inquiries from relatives.'

The other feature of the Alder Hey inquiry was vilification of pathologists by the press. It has left many angry at the DoH for failing to defend them adequately.

'We have been turned into ogres who like to cut up dead babies, ' says Irene Scheimberg, consultant paediatric pathologist at the Royal London Hospital. 'It is been very demoralising as all I ever wanted to do was to help parents in a very distressing situation.'

The consequences of the strain on services are far-reaching. Post mortems provide valuable information that can influence management of a future pregnancy. They are crucial to research and understanding the causes of death.

Queen's Medical Centre in Nottingham pathology professor Jim Lowe says: 'Getting rid of routine post-mortems is like sailing a cruise liner across the channel with your radar switched off. Paediatric pathology is our radar - it tells us what we are doing and where we are going wrong. Without it you will soon run onto the rocks.'

It is not just post-mortem services that are suffering, he adds.

Diagnosis of children's cancer is also being delayed.

'When a child presents with a lump, the surgeons swing into action. But before you can proceed with any treatment you need a diagnosis from a paediatric pathologist, ' he says.

'At the moment there are delays and emotionally it is almost intolerable for both the parents and the clinical staff.You try to do it as quickly as you can but sometimes you have to say, 'come back next week'.'

So far, pathologists have been able to prioritise cancer diagnoses - albeit at the expense of routine post-mortems. That may not be the case for much longer.

Professor McIntosh says there is a real risk that the point will be reached when cancer diagnoses are delayed to a dangerous extent.

'Certainly there is a risk of that happening. You cannot foresee when, but if you have a problem with post-mortems, then cancer biopsies cannot be far behind.'

The working party's report, published by the Royal College of Paediatrics and Child Health, sets out 35 recommendations to address the current situation. Its authors are now awaiting a response from the DoH.

'The most important thing we need is a strategic review, ' says Professor McIntosh. 'If it is convened by the government perhaps it would feel obliged to act on it.'

Paediatric pathologists have been unable to defend themselves against the bad press.The government may be wise to act before Professor McIntosh's predictions on children's cancer services prove right and ministers are in the headlines instead. l A privilege, not a right Royal London Hospital consultant paediatric pathologist Dr Irene Scheimberg was on holiday in Spain earlier this year when a colleague called from London requesting her to do a post-mortem.

'I was walking in the park with my son and said no, I couldn't do it, and he should try elsewhere.

That was Thursday.When I came back to the office on Monday, I was called again. I asked if this was the same case.They said yes, they had tried every hospital in London, Oxford and Cambridge with no luck.'She agreed to do it on the next Thursday.'The parents and the doctor were prepared to wait a week to have access to something that should be a right, but is in fact a privilege.'

Dr Scheimberg regularly turns down post-mortem requests.She writes her reports at home after her six-year-old son is in bed.'I do not have a secretary. I do not have a colleague on site as I am single-handed. If I want to discuss a case I have to do it over the phone or by e-mail. It is time the government took this seriously.'

The Future of Paediatric Pathology Services .

Royal College of Paediatrics and Child Health.

www. rcpch. ac. uk/publications/ recent_publications. html