• More than 3,000 patients were recalled
  • Royal college review was approved in September 2018
  • Harm review will not be published, says trust

A royal college’s review of quality concerns at a pathology service — first approved in September 2018 — has yet to get underway, HSJ has been told.

Failings in a merged pathology service based at Dartford and Gravesham Trust led to more than 3,000 patients being recalled in late 2018 and early 2019. 

Errors flagged included tests which could have shown acute kidney injury not being reported to GPs promptly; running out of essential supplies; failing to secure blood samples; tests not being processed in time; and GPs being unaware of test outcomes due to the way they were sent.

The new service — North Kent Pathology Services — handles samples for both Dartford and Gravesham and Medway Foundation Trust, with non-urgent tests for both trusts being carried out at its laboratory in Dartford. The service went live in April 2018, while blood sciences were centralised from June 2018. 

HSJ reported in 2019 that a Royal College of Pathologists review had been approved in September 2018, although the trust said it was eventually “commissioned” in April 2019 and the finance director did not sign off the contract until July 2019.

The trust has now told HSJ in a statement: “Following review and agreement of revised terms of reference, we are awaiting a start date from the royal college.”

It said the review’s terms of reference were to review and advise on the governance arrangements now in place for the pathology service; review and advise on the response to the incidents including remedial actions; and, based on a separate harm review process, evaluate lessons learnt.

The trust said the harm review, which has been submitted to NHS Improvement for review, will not be made public, as it contains sensitive patient information.

The trust had also said there were internal and external reviews of the service which have already been carried out. When asked by HSJ for copies of these, however, it said these are “not all formal reports but represent a series of rolling investigation and actions to respond to incidents and risks within NKPS”.

The four Kent acute trusts — Dartford and Gravesham, Medway, Maidstone and Tunbridge Wells Trust, and East Kent Hospitals University FT — are planning to form a single pathology service, although no decision has been taken on what this will look like. It is expected learning from the NKPS will inform the development of the new service.