Plea for CHAI to inspect path labs

Pathology laboratories should be subject to inspection by the Commission for Healthcare Audit and Inspection in the wake of the Alder Hey and Bristol inquiries, an independent review has urged.

The two-year review commissioned by the Department of Health makes 122 recommendations which also widen the remit of coroners in making verdicts, strengthen the rights of the bereaved and tighten up the process of certifying deaths.

The review suggests work done by consultant pathologists for coroners should be included in their appraisals, and that CHAI should periodically undertake thematic inspections of pathology done for coroners. It says:

'...much coroners' pathology is done in NHS mortuaries and laboratories. The Alder Hey and Bristol reports show there is a need for proper scrutiny of practice in this sensitive area... Regular, proactive and independent checks would be a worthwhile safeguard.'

CHAI should also be able to raise concerns with coroners about individual deaths, with coroners obliged to pass on information which is relevant to its work. The report calls for fuller use to be made of autopsy findings, so that matters potentially of interest to clinical practice, public health and safety should be passed on to individual GPs, public health interests in strategic health authorities, CHAI or the National Patient Safety Agency.

The review, headed by retired civil servant Tom Luce, also addresses concerns raised by the public inquiry into the case of GP Harold Shipman.

Under the reforms, an independent second doctor would certify the cause of death and new statutory medical assessors, employed to support coroners' investigations, would be able to audit the process of care home death certification.

And it calls for primary care trusts to arrange for qualified independent nurses to attend nursing homes to verify death.

The Medical Defence Union's medico-legal adviser Dr Peter Schutte welcomed the report. He said: 'Inquests need to go further than applying a label to individual deaths. They need to ensure that patterns and trends are recognised and lessons learned from experience, particularly of preventable deaths. The suggestions that inquests will focus more on learning lessons is a very welcome one and echoes the move towards transparent practices that is going on throughout the health service.'

www. official-documents. co. uk /document/cm58/5831/5831. htm