Dear Mr Arrow

Re : Inquest touching the death of David Hulme ; Inquest Date – 27/06/2022

At the conclusion of the above referenced inquest, you determined that under the powers granted to you by paragraph 7, schedule 5 of the Coroner and Justice Act 2009 and Regulations 28 and 29 of the Coroner (Investigations) Regulations 2013 that you would write to University Hospitals Plymouth NHS Trust (UHP) with a Preventing Future Deaths Report.

We have now received that report and note your concerns are as below:

“I am concerned that the Pathology Department remains significantly under resourced.

I ask you please to: (1) Review the Consultants staffing levels in the Pathology Department particularly those Consultants dealing with Thoracic work so as to ensure timely and accurate diagnosis of conditions at this regional centre”

As part of the inquest process UHP provided you with a copy of the Root Cause Analysis Report (RCA) which identified the need for additional Consultant resource within the Pathology Department to which your concern is directed.

The evidence submitted both within the RCA and via a further report, authored by the Pathology Operations Manager, confirmed that the business case to appoint further Consultants into the Pathology Department had been approved with funding allocated to this end. It was stated that the recruitment process would commence as soon as possible.

I can confirm that UHP have approved the funding for 4 x Consultant Pathologist posts and whilst we cannot guarantee a date that these posts will be filled, we hope to recruit into these posts as soon as possible and are in an active recruitment phase.

We would ask you to note however that there is a national shortage of suitably qualified clinical staff practicing in this field and thus whilst we shall pursue these appointments with our best endeavours the recruitment may be a protracted process.

Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.

We trust this response can assure you of our commitment to providing a suitably staffed Pathology Department and our commitment to the safety of all patients within the whole South West region.