User Information

The Black Country Pathology Service is currently working to achieve a single quality management system across the network. Currently, we are transitioning to implementing a single quality management system software, a single laboratory information management system and standardised equipment.

The BCPS is a UKAS (United Kingdom Accreditation Service) accredited medical laboratory number: 8663, 9482, 8657, 9578, 8665, 8655, 9580 and 8407.

Our accreditation is limited to those activities described on our UKAS schedule of accreditation, can found at Who’s Accredited? – UKAS

Tests not appearing in the schedule are Not UKAS accredited. These tests however, are performed by the same trained and competent staff.

Blood Transfusion services are regulated by the Medicines & Healthcare products Regulatory Agency (MHRA) and the Histopathology laboratory is approved by, and registered with, the Human Tissue Authority (HTA).

The laboratory adheres to The Royal Wolverhampton NHS Trust policies on data protection and disclosure. The following policy can be found on the Trusts intranet site, Information Governance Policy OP13. BCPS acts as the ‘guardian’ of data generated as a result of diagnostic activities undertaken on your sample(s).

Everyone working for the NHS has a legal duty to keep information about you confidential and secure under the Data Protection Act 1998 and the Caldicott principles. We use the minimum amount of information required to inform the people who need to know to provide your care. For further information visit the Trust website ‘information for patients/ My information’.

Requests, where possible should be made electronically. The adhesive specimen labels provided must be adhered to each specimen container to ensure ALL samples are clearly labelled.

Information about the specimen together with the date and time (please use the 24 hour clock) is important for both correct specimen identification and interpretation. The type of specimen, fasting or dietary status, site of infection, clinical details and duration of symptoms (for microbiology the date of onset of symptoms or date of contact are often vital in selecting and interpreting serological tests), details of antibiotic therapy (microbiology) and drug therapy (toxicology) may all be relevant.

It is important that both the form and container are fully completed and correctly labelled, including the identity of the person collecting the sample. In general, unlabelled specimens will not be processed and poorly labelled samples will only be processed if it is safe to do so.

For ‘private’ patients, the appropriate box must be ticked on the request form. If no box is ticked it will be assumed that the patient is NHS.

Laboratory departments are not obliged to accept incorrectly or inadequately labelled specimens or request forms. The completion of the request form is the responsibility of the requestor, for more information see [link to acceptance and rejection SOP].

Urgent Requests

The word ‘urgent’ must be confined to specific test requests that will immediately affect the management of a case. You may request non-urgent tests on the same sample, but these should be clearly identified on the request form. Unlabelled and mislabelled samples will not be accepted.

To ensure urgent samples can be prioritised by the laboratories please ensure all routine samples are placed in the clear specimen bag; the red bag should only be used for urgent specimens.

Occasionally the laboratory must reject specimens for testing for the following reasons:

• The request made is inappropriate
• The names on the specimen and the request form do not match
• Insufficient information is provided on the request form to determine the test required (if no test is stated, a basic screen may be performed)
• The specimen submitted is unsuitable for the investigation required
• The specimen fails to comply with safety protocols
• Damage to the specimen container at some stage has resulted in leakage or total loss of the specimen
• The quality of the specimen is inadequate, e.g. too old, haemolysed, insufficient sample, etc.
• The specimen or request form is not labelled.

Where appropriate (precious/ non repeatable sample) the laboratory will contact the ward/clinician in order to resolve the problem. A written report giving the reason why a specimen has been rejected will be issued.

Sometimes when serological investigations are requested serum will be stored in the laboratory rather than being tested immediately. This may be because the clinical details provided are insufficient to determine the appropriate investigation, or because useful information will only be obtained by testing a convalescent serum specimen in parallel. In all such instances a written report indicating that the specimen has been stored will be issued within one working day of receipt.

Further details can be found in our SOP on sample acceptance & rejection.

BCPS Specimen Rejection SOP

All staff are required by the Health and Safety at Work Act to take reasonable care for their own safety and that of other people who may be affected by their actions. Laboratory work is hazardous and clinical staff are often in a position to warn laboratory staff when extra precautions are necessary for certain specimens. All specimens should be accompanied by a request form and safely packaged for transport to the laboratories.

All specimens are potentially an infection risk and must be handled carefully. However, additional precautions are necessary for certain specimens from patients known, or suspected to have infections that may be transmitted to laboratory and other health care workers. These MUST be labelled as biohazard. Specimens from patients with haemophilia, infective liver disease, Hepatitis B who are HbsAg, HIV anitbody positive, Typhoid/ Paratyphoid fever, Q fever,  Amoebic dysentry or Creutzfeldt-Jacob disease are particularly hazardous to laboratory personnel.

Requests involving specimens that may contain cytotoxic drugs should be clearly identified on the request form.

COVID-19 samples should be labelled with either Priority 10 or Priority 20 labels.

Appropriate highlight or biohazard (Danger of Infection) labels must be attached to request forms and specimen containers. Lids of specimen containers must be securely tightened and the containers securely sealed within the specimen transport bag which is then attached to the request form.

Please contact the appropriate discipline if you wish to discuss individual cases.

BCPS operates a complaints system in line with the Royal Wolverhampton Hospital NHS Trust complaints policy. Our objectives are:

• To respond in an open, positive and professional manner
• To ensure the patient/ user difficulties are alleviated
• That the same problem will not occur again due to corrective actions taken
• Patient/ user confidence is restored in our services
• Records of complaints are recorded and reported to the BCPS Chief Medical Officer and the BCPS Operations Manager

Complaints or suggestions regarding the services provided by pathology can be made verbally or in writing (letter or email) to rwh-tr.complaints@nhs.net. If the service provided is not satisfactory, please contact the BCPS Operations Manager or the BCPS Quality Team to progress the complaint. Please be aware that complaints can also be made directly to the Trust and support is available from ‘Patient advice liaison services, email rwh-tr.PALS@nhs.net.