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8440 Medical Multiple Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines-upon-Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South East London Pathology Partnership Issue No: 005 Issue date: 23 August 2021 Queen Elizabeth Hospital Contact: Melanie Williams-Dogbe 8440 Stadium Road Tel: +44 (0) 208 836 6000 ext. 5672 Woolwich E-Mail: [email protected] Accredited to SE18 4QH Website: www.lewishamandgreenwich.nhs.uk ISO 15189:2012 Testing performed by the Organisation at the locations specified below Locations covered by the organisation and their relevant activities Laboratory locations: Location details Activity Location code Address Local contact Queen Elizabeth Hospital Kathleen kidd Routine Histopathology QEH Stadium Road Special Stains Woolwich Tel: +44 (0) 208 333 3000 ext. 8478 Immunohistochemistry SE18 4QH E mail: [email protected] Immunology Clinical Biochemistry Haematology Blood transfusion University Hospital Kathleen Kidd Clinical Biochemistry UHL Lewisham Haematology High Street Tel: +44 (0) 208 333 3000 ext. 8478 Blood transfusion Lewisham E mail:[email protected] London SE13 6LH Assessment Manager: SW3 Page 1 of 32 Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines -u po n - Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South East London 8440 Pathology Partnership Accredited to Issue No: 005 Issue date: 23 August 2021 ISO 15189:2012 Testing performed by the Organisation at the locations specified Site activities performed away from the locations listed above: Location details Activity Location code Blood Sciences Laboratory Blood storage (stock/issue) QEH Queen Elizabeth Hospital Fridge managed by laboratory Stadium Road Woolwich SE18 4QH Ward 21 Haematology/Oncology Blood storage only QEH Queen Elizabeth Hospital Fridge managed by laboratory Stadium Road Woolwich SE18 4QH Theatres Blood storage only QEH Queen Elizabeth Hospital Fridge managed by laboratory Stadium Road Woolwich SE18 4QH Blood issue room Blood product storage (Stock/issue) UHL Rapid response laboratory Fridge managed by laboratory University Hospital Lewisham High Street Lewisham London SE13 6LH Main TheatrePaediatric Blood storage UHL University Hospital Lewisham Fridge managed by laboratory High Street Lewisham London SE13 6LH Assessment Manager: SW3 Page 2 of 32 Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines -u po n - Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South East London 8440 Pathology Partnership Accredited to Issue No: 005 Issue date: 23 August 2021 ISO 15189:2012 Testing performed by the Organisation at the locations specified DETAIL OF ACCREDITATION Materials/Products tested Type of test/Properties Standard specifications/ Location measured/Range of Equipment/Techniques used Code measurement HUMAN BODY TISSUE Histopathological examination In-house documented procedures QEH activities for the purposes of using manual methods or clinical diagnosis analysers in conjunction with manufacturers’ instructions as specified: Tissue samples (including Examination of tissues in order Supported by: breast; gastrointestinal; skin; to identify or exclude urological; morphological and cytological Specimen dissection: bronchial/lung/thoracic; abnormalities for the purpose Cut-up Manual - Routine endocrine including thyroid, of diagnosis Specimens categorised parathyroid, adrenal; according to the RCPath as, lymphoreticular including SOP CHQ-DP-008 & SOP CHQ- lymph nodes, spleen, and DP-009, CHQ-RP-00013 & CHQ bone marrow trephines DP 0010 [processing only for bone ‘A’ specimens marrow trephines]; liver; ‘B’ specimens bone and soft tissues; , ‘C’ specimens gynaecological; and head ‘D’ specimens and neck) Formalin Fixed Tissue Decalcification using acid decalcifiers (Decalcifier 1 and 2) SOP CHQ-DP-0010 Processing using Sakura TissueTek VIPs ; VIP5 : SOP CHQ-MP-0026 VIP6 : SOP CHQ-MP-0065 Embedding using : Tissue tek Embedding Centre SOP CHQ- MP-005 Formalin Fixed Paraffin Microtomy: Using rotary Embedded Tissue (FFPE) Microtomes, Shandon Finesse, Leica (SOP CHQ-MP-006, CHQ- MF-0024) Macroscopic and Microscopic examination: Documented in- house procedures for staining for staining and reading Assessment Manager: SW3 Page 3 of 32 Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines -u po n - Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South East London 8440 Pathology Partnership Accredited to Issue No: 005 Issue date: 23 August 2021 ISO 15189:2012 Testing performed by the Organisation at the locations specified Materials/Products tested Type of test/Properties Standard specifications/ Location measured/Range of Equipment/Techniques used Code measurement HUMAN BODY TISSUE Histopathological examination In-house documented procedures QEH (cont’d) activities for the purposes of using manual methods or clinical diagnosis (cont’d) analysers in conjunction with manufacturers’ instructions as specified: Demonstration Of: Formalin Fixed Paraffin Basophilic and eosinophilic Haematoxylin and Eosin staining Embedded Tissue (FFPE) structures SOP CHQ-SP-001 in conjunction sections on glass slides with manufacturer’s instructions for Leica Autostainer Special Tinctorial Histochemical Staining: Acid Mucopolysaccharides Alcian Blue (SOP CHQ-SP-003) Acid and Neutral Alcian Blue/Periodic Acid Schiff Mucopolysaccharides (SOP CHQ-SP-002) Amyloid Congo Red (SOP CHQ-SP-005) Elastic fibres and connective Elastic/Haematoxylin Van Gieson tissue (EVG/HVG) (SOP CHQ-SP-007, CHQ-SP-014) Bile pigments Fouchet van Gieson (SOP CHQ- SP-008) Fungi including Pneumocystis Grocott Hexamine Silver (SOP- jiroveci (carinii) CHQ-SP-013) Mucin; Cryptococcus Mucicarmine (SOP CHQ-SP- 0020) Helicobacter/Microorganisms Giemsa (SOP CHQ-SP-009) Gram +ve & -ve Gram (SOP CHQ-SP-0011) microogranisms Connective tissue and fibrin Martius Yellow, Brilliant Crystal Scarlet, Soluble Blue (MSB) (SOP CHQ-SP-0019) Assessment Manager: SW3 Page 4 of 32 Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines -u po n - Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South East London 8440 Pathology Partnership Accredited to Issue No: 005 Issue date: 23 August 2021 ISO 15189:2012 Testing performed by the Organisation at the locations specified Materials/Products tested Type of test/Properties Standard specifications/ Location measured/Range of Equipment/Techniques used Code measurement HUMAN BODY TISSUE Histopathological examination In-house documented procedures QEH (cont’d) activities for the purposes of using manual methods or clinical diagnosis (cont’d) analysers in conjunction with manufacturers’ instructions as specified: Demonstration Of: (cont’d) Formalin Fixed Paraffin Special Tinctorial Histochemical Embedded Tissue (FFPE) StainingCont’d.: sections on glass slides Melanin, Argentaffin cells and Masson Fontana (SOP CHQ-SP- Lipofuchsin 0016) Connective tissue Masson’s Trichrome (SOP CHQ- SP-0017) Neutral Mucopolysaccharides, Periodic Acid Schiff (PAS) & glycogen and fungus Diastase PAS (D/PAS) (SOP CHQ-SP-0023) Haemosiderin and ferric iron Perl’s Prussian Blue (SOP CHQ- SP-0024) Reticulin fibres Reticulin- Gordon & Sweets (SOP CHQ-SP-0010) Copper-associated protein and Shikata’s Orcein (SOP CHQ-SP- Hepatitis B-affected cells 0022) Mast cells Toluidine Blue (SOP CHQ-SP- 0028) Tubercle bacilli Ziehl Neelsen (ZN) (SOP CHQ- SP-0021) Melanin bleach Mallory Melanin Bleach (SOP CHQ-SP-0015) Leprosy bacilli Wade-Fite (SOP CHQ-SP-0029) Assessment Manager: SW3 Page 5 of 32 Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines -u po n - Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South East London 8440 Pathology Partnership Accredited to Issue No: 005 Issue date: 23 August 2021 ISO 15189:2012 Testing performed by the Organisation at the locations specified Materials/Products tested Type of test/Properties Standard specifications/ Location measured/Range of Equipment/Techniques used Code measurement HUMAN BODY TISSUE Histopathological examination In-house documented procedures QEH (cont’d) activities for the purposes of using manual methods or clinical diagnosis (cont’d) analysers in conjunction with manufacturers’ instructions as specified: Formalin Fixed Paraffin Immunohistochemistry to Ventana Benchmark stainer Embedded Tissue (FFPE) detect the following: SOP (CHQ-IP-0015) in sections on glass slides conjunction with manufacturers (cont’d) instructions Incorporating the following antibodies: Embryonic cell in normal Alpha Fetoprotein tissues and germ cell tumours Cytokeratins (acidic, basic) AE1/AE3 HGPIN, prostate AMACR (Racemase) adenocarcinoma T lymphocytes, follicular Bcl2 oncoprotein lymphoma, basal cell carcinoma Epithelial cell types Ber Ep4 Pancreaticobiliary CA 19.9 adenocarcinomas Ovarian tumours CA 125 Smooth muscle Caldesmon Myoepithelial cells, smooth Calponin muscle cells Mesothelial cells Calretinin Glandular cells CAM 5.2 T cells CD3 Mature T cells, T cell CD5 lymphomas Assessment Manager: SW3 Page 6 of 32 Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines -u po n - Thames, TW18 3HR, UK Barts Health NHS Trust as the host of NHS East and South
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