Recurance · prevention of future deaths reports
Pre-inquest brief
Inaccurate post mortem sampling in suspected anaphylaxis cases
The earlier warning
Christopher Byron · 5 Nov 2019 · Joanne Kearsley, Manchester (North)
“The quality of the post mortem examination report produced i was wholly unsatisfactory and proven inaccurate.”
What was promised
Stated action 1 · response to Celia Marsh (21 Nov 2022) · stated timescale: none stated
“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.”
judiciary.uk/…/2022-0379-Response-from-Royal-College-of-Patholo…
What recurred
- 21 Nov 2022 · Celia Marsh · Maria Voisin · Closely related · confidence 0.92 (high)
- 25 Nov 2025 · Benedict Blythe · Elizabeth Gray · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Christopher Byron · 5 Nov 2019
“The quality of the post mortem examination report produced i was wholly unsatisfactory and proven inaccurate.”
Later · Celia Marsh · 21 Nov 2022
“- If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing”
What happened next
No web check of the stated actions has been published for this chain.