Inaccurate post mortem sampling in suspected anaphylaxis cases
Royal College of Pathologists received 3 coroners' reports about this hazard between 5 Nov 2019 and 25 Nov 2025.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The quality of the post mortem examination report produced i was wholly unsatisfactory and proven inaccurate.”
Original on judiciary.uk ↗ No published response from Royal College of Pathologists was found for this report.
- 3 years 1 month laterClosely relatedConfidence 0.92 · higha different coroner
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
Original on judiciary.uk ↗ Royal College of Pathologists responded, stating 1 specific action.Response (PDF) ↗
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”
- 3 years later
Raised again · 2nd time
Benedict Blythe↗
25 Nov 2025 · Elizabeth Gray · Cambridgeshire and Peterborough
Closely relatedConfidence 0.90 · higha different coroner“a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen”
Original on judiciary.uk ↗ Royal College of Pathologists responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Royal College of Pathologists
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2022Celia Marsh3 years 1 month after Christopher Byron · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports identify deficiencies in the post‑mortem examination process that affect the accuracy of cause‑of‑death determinations.
Christopher Byron · 5 Nov 2019
“The quality of the post mortem examination report produced i was wholly unsatisfactory and proven inaccurate.”
Original on judiciary.uk ↗ Celia Marsh · 21 Nov 2022
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
Original on judiciary.uk ↗ 2022 → 2025Benedict Blythe3 years after Celia Marsh · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports call for improved post‑mortem sampling in suspected anaphylaxis cases, especially retaining blood and stomach contents for allergen testing.
Celia Marsh · 21 Nov 2022
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
Original on judiciary.uk ↗ Benedict Blythe · 25 Nov 2025
“a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”
No published response from Royal College of Pathologists was found for this report.
Stated action
“The Royal College of Pathologists is currently updating its autopsy practice guidelines for suspected acute anaphylaxis. The updated guidelines will include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases to the UKFAR.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Royal College of Pathologists at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2022 | 0.63 | 0.24 | Closely related · 0.92 | different |
| 2022 → 2025 | 0.88 | 0.59 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.