Recommendation R3: Paediatric pathology in unexpected child deaths
From The Allitt Inquiry Report, published 11 February 1994.
Recommendation
We recommend that the provision of paediatric pathology services be reviewed with a view to ensuring that such services be engaged in every case in which the death of a child is unexpected or clinically unaccountable, whether the post mortem examination is ordered by a Coroner or in routine hospital practice (para 4.2.16)
Government response
Recommendation 3. We recommend that the provision of paediatric pathology services be reviewed with a view to ensuring that such services be engaged in every case in which the death of a child is unexpected or clinically unaccountable, whether the post mortem examination is ordered by a Coroner or in routine hospital practice. This recommendation has been considered by the Strategic Review of Pathology Services which advises that more work is required on a number of detailed operational issues. A Working Group to look at the issues involved will be set up.
Delivery
DHSC and NHS England state no delivery position (27 February 2026)
Please see response to recommendation 2.
This recommendation has been superseded by:
• Working together to safeguard children, which provides that: “The designated doctor for child deaths should be a senior paediatrician who can take a lead role in the review process.
• Child Death Review Statutory and Operational Guidance, which includes the appointment of a senior paediatrician to take a lead in co-ordinating responses and health input to the child death review process, across a specified locality or region.
Additionally, a new statutory medical examiner system was rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. All deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. The changes, which form part of the Department of Health and Social Care’s Death Certification Reforms, were announced by the government on 15 April 2024, and came into force on 9 September 2024. This built on the initial introduction of medical examiners on a non-statutory basis from 2019/20.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Superseded”. Table row: section 3.2 No. 3, PDF page 14.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
In November 1994, the Secretary of State for Health said that this recommendation had been considered by the Strategic Review of Pathology Services, which had advised more work was required on a number of detailed operational issues. The Secretary of State said a Working Group to look at the issues involved would be set up. The current position is that a treating clinician is able to request a hospital post-mortem to further investigate a cause of death, but informed consent must be sought.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 3.2 No. 3, PDF page 14-15.
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding