The Pathology Service at Derriford Hospital comprises several departments and a small administrative office, which acts as the interface with other clinical and service departments.
Derriford Combined Laboratory (DCL) is made up of several sections: Clinical Biochemistry, Haematology, Blood Transfusion, Coagulation, Immunology and Molecular Biology. Detailed information relating to blood transfusion is covered in the Hospital Transfusion Manual, which is available on all wards and departments.
The Cellular Pathology Department includes Histopathology, Cytopathlogy, Neuropathology and Anatomical Pathology.
Microbiology provides laboratory services and the control of infection team.
The phlebotomy service to the Trust is also provided by the Pathology Directorate.
Reports are primarily available electronically and, in some instances, paper form. All networked computers within the Trust have access to blood, microbiology and cellular pathology results as soon as they are available (which for many blood tests will be within a few hours of receipt). Electronic access to results is also available to GP practices through ICE.
The directorate aims to give the highest quality of service and various parts of the service are accredited and/or regulated by UKAS, JACIE, HTA and MHRA.
UKAS Accreditation and Tests
All three laboratories at Plymouth Hospitals NHS Trust are accredited to the International Standard ISO 15189:2012 Medical Laboratories – requirements for quality and competence;
Microbiology (Serology and Bacteriology): UKAS accredited medical laboratory No. 8050.
Cellular and Anatomical Pathology, (Including Histology, Cytology, Neuropathology and Mortuary): UKAS accredited medical laboratory No. 9881.
Combined Laboratory: Coagulation, Biochemistry (Automated & Special Investigations), , Immunology (Diagnostic and Histocompatibility & Immunogenetics), Transfusion Laboratory: UKAS accredited medical laboratory No. 9088.
The Schedules of Accreditation can be found here:
Schedule of Accreditation Microbiology 8050.pdf
Schedule of Accreditation: Combined Laboratory 9088.pdf
Schedule of Accreditation Cellular & Anatomical Pathology 9881.pdf
As a dynamic pathology service, that continually seeks to improve for the benefits of patients, there are a number of tests and processes that are being developed or amended between accreditation visits. Until they have been ratified by the annual UKAS assessment process, these new/amended tests/processes are not covered by the current schedules of accreditation. However, our users should be assured that the laboratories subject these tests to the same high level of quality assurance protocols to those that are UKAS accredited.
List of currently non-accredited tests.pdf
External Quality Assurance programmes
All laboratories participate in recognised External Quality Assurance schemes and regular Internal Quality Control checks.
Incidents and Complaints
All incidents and complaints are investigated and subsequent corrective and preventative actions are introduced where needed. Internally any complaints received are shared and discussed at a Departmental and Directorate management meetings.
See individual laboratory details for following the complaints process or contact the Quality Team via the Contact Pathology page.
Responsibility of the Sender: The responsibility for safe collection and packing rests entirely with the sender. All samples must be presented to the person undertaking the transport in a safe and suitable manner that complies with all necessary regulations.
Derriford Hospital Users: Derriford Hospital has a pneumatic tube system for transporting samples to the laboratories. However, this system should not be used for transporting CSF samples for bilirubin (‘xanthochromia’), histopathology and cytopathology samples. Routine Histopathology (including neuropathology specimens) and cytopathology specimens will be collected by the specimen porters as part of their normal round. See below for delivery of Urgent specimens.
Pathology specimens must be sent in red pods only. Green pods are for pharmacy paperwork only. In the event of a problem, please report to the Estates Department on Ext: 52029. Outside of normal working hours a 24 hour call –out service is provided by the Estates Department (the Duty Estates Supervisor can be contacted via switchboard).
Urgent specimens requiring results for the immediate management of the patient should be hand delivered to the laboratory, ensuring that the urgency is communicated to laboratory staff.
Courier services for general practices: A GP specimen collection service is provided by PHNT based at Hatfield House. This service also provides transport for other services including Imaging, Pathology Issue Stores and mail.
In addition, Derriford Combined Laboratory’s Blood Bank vehicles provide a limited specimen collection service.
Urgent specimens should be handed separately to transport staff, who will ensure that they are delivered appropriately to laboratory staff. This facility is for requests requiring results for the immediate management of the patient. Urgent requests are regularly audited.
Specimens for urgent analysis, which are delivered to the laboratory by Taxi or other transport: These should be hand delivered to the appropriate laboratory and should not be left at the main reception.
Specimens from other centres: These should be delivered to the appropriate laboratory and transported in accordance with relevant legislation. Advice on the safe transport of specimens is available by using the link to the Pathology specimen transport policy below or from the Pathology directorate.
IATA Dangerous Goods (DG) Regulations: This states that members of the public should be protected from the risks of potentially infectious substances. A code of practice for staff involved in specimen transport is available on request from the Pathology Directorate office.
Pathology specimen transport policy: This document gives advice on the transport of specimens and is available here.
Specimen risks to laboratory staff
- All biological specimens are a potential hazard to hospital staff and should be safely contained when transported to the laboratory.
- The specimen container must describe the nature of the specimen, correct patient details, and the patient’s location.
- Each specimen must be placed in a clean specimen bag and correctly sealed.
- If a specimen is known or suspected to pose an increased risk of infection, it is the responsibility of the individual taking the sample to ensure that this information is made known to laboratory staff. This will allow laboratory staff to take additional precautions where appropriate.
- The request form MUST give sufficient clinical information to specify the suspected, or known infection
NOTE: The Health and Safety Executive has recently highlighted the lack of clinical details as resulting in samples being handled in laboratories at the wrong biological containment level, thereby placing laboratory staff at increased risk (HSE Bulletin No. HID 5-2011).
Examples of specimens which pose an increased risk of infection:
- Any specimen from a patient suspected of having TB, typhoid, anthrax or brucellosis
- Stool specimens from patients with haemorrhagic colitis (bloody diarrhoea), haemolytic uraemic syndrome, or suspected of having VTEC/STEC including E. coli 0157 infection.
- Stool specimens from patients with suspected dysentery (Shigella)
- Any specimen from a patient suspected of having a spongiform encephalopathy (e.g. CJD)
- Blood samples for HIV or Hepatitis tests. In addition, viral load specimens should be ‘double-bagged’
- Any specimen from a patient suspected of having viral haemorrhagic fever. These must be discussed with the on-call Consultant Microbiologist prior to submission to the laboratory.
Under no circumstances should a specimen be sent in a leaking or contaminated container. The laboratory may dispose of hazardous specimens without testing them if the sample presents a risk to staff due to inadequate information or packaging.
Ebola Virus Disease and other viral haemorrhagic fevers: Whenever a diagnosis of viral haemorrhagic fever is entertained, always discuss the case with the on-call Consultant Microbiologist before submitting clinical samples to the laboratory.
The Trust Guidelines has guidelines for Viral Haemorrhagic Fevers.
Consent for Research
It is important that the box on the request form indicating the patient’s wishes regarding use of surplus tissues for research is completed accurately, and that this information matches what is recorded on an operation consent form, so that research using tissue samples can be carried out in compliance with the patient’s wishes and the Human Tissue Act.
Pathology Computer Systems
Medical, nursing and other staff can access biochemistry, haematology, immunology and microbiology pathology test results using computers linked to the Trust network.
As part of a modernisation initiative the directorate is developing an electronic requesting system, so that in the future paper request forms may not be required.
Passwords to pathology computer systems are available from the relevant Systems Manager, for those who have a valid reason to access test results.
- Adrian Heathcote -Combined Labs IT Manager
- John Siewruk – Cell. Path. & Microbiology IT Manager
- Paul Tucker – Pathology IT Specialist
- Sky Fletcher – IT Technician
- Simon Harries – Pathology IT Admin Support
Laboratory consumables, for example blood vacutainer tubes, specimen containers, specimen bags and labels are available from the Pathology Stores, located within the Pathology stores at UHP Estover..
Supplies are sent out on receipt of the appropriate requisition form; telephone orders are only accepted for urgent items. Many items have a short shelf-life so please do not over-order.
Please note the following are issued by the Combined Laboratory (Tel 433217, option 7) not Stores, and come complete with instructions
- 24 hour Urine collection containers (Plain and Acid)