Policy paper

Response to the Hillsborough pathology review

Published 5 October 2022

The Home Office confirms the establishment of an independent review of the forensic pathology response to the Hillsborough disaster, following recommendations from the Right Reverend James Jones’ 2017 report. The Review commenced on 1 July and is chaired by Mr. Glenn Taylor. The terms of reference are as follows:

Terms of Reference

Terms of Reference for the Review of the service provision of Forensic Pathology:

This document sets out the terms of reference for providing a response to the Hillsborough Inquiry ‘The Patronising Disposition of Unaccountable Power: A Report to ensure the pain and suffering of the Hillsborough families is not repeated’ ‘Point of Learning’ Recommendation 15.

The Pathology Delivery Board (PDB) will appoint an independent professional to conduct a review and submit a report to Ministers on the following issues identified in the above-named report (page 103):

1. Take heed of the failures in the pathology following the Hillsborough Disaster which were identified at the final inquests
2. Make an assessment as to whether there is a risk of the same failures occurring should there be another similar mass fatality event by reviewing similar mass fatality incidents that have occurred in the last ten years
3. Describe whether there are adequate safeguards currently in place in terms of clinical governance, revalidation as well as regulatory and managerial oversight of Home Office forensic pathology provision in England and Wales to respond to such mass fatality incidents;
4. Assess whether the process of accountability of practitioners is now sufficient and fit for purpose compared against the system in operation at the time of the original inquests, and;
5. Consider if there were any lessons learnt from the Hillsborough disaster which can be embedded into the continuous professional development of Home Office registered forensic pathologists and the wider provision of pathology services.

It is not intended that the review will expand its scope beyond the above issues into a fundamental review of the structure of the profession. This is in recognition that such a review has already been recently completed in 2015 by Professor Hutton. It should focus on examining the issues and failures identified at the final inquests, whilst recognising that it will want to take account of the review undertaken by Professor Hutton in 2015. It should also focus on any improvements which can be made to the current delivery model, and not be a re-investigation of the events on the day of and the days following the disaster.

Point of learning 15 – Pathology failures at the first inquests

It is difficult to overstate the impact of the failures of pathology at the first inquest.

The impact is deeply personal for those families who feel they will now never know how their loved one died, but it also has a wider resonance – leading as it did to the necessity for new inquest proceedings 25 years after the disaster occurred.

Given that impact, that there should be proper consideration of the potential for learning from the failings of the pathology evidence to the original inquests. A review should be commissioned by the Pathology Delivery Board, which oversees the provision of forensic pathology services in England and Wales and delivered independently. As well as reviewing how the evidence at the first inquests came to be misleading and why, the review should also consider whether there are adequate safeguards to prevent it happening again, including clinical governance and revalidation processes that are made more difficult by the small size of the subspecialty of forensic pathology and its distinctive employment mechanism. This review should also consider whether a process of accountability is appropriate in respect of the misleading evidence presented at the original inquests.

Finally, the review should consider how to embed the lessons from the Hillsborough experience in the continuous professional development training of pathologists.