Susan Mayor

A quarter of reports on autopsies requested by UK coroners are poor or unacceptable, concludes an audit of coroners’ autopsy practice. The audit report calls for national criteria and standards to improve the quality of autopsies.

The report reviewed coroners’ autopsies from one week in May 2005 in England, Wales, Northern Ireland, Guernsey, Jersey, and the Isle of Man. Scotland was not included because it operates under a different legal system.

Sebastian Lucas, one of the report’s authors and clinical coordinator at the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), an independent body that reviews the quality and safety of medical care, said: “We don’t manage death well in this country. It is important that the aim of coronial autopsy is clarified. We want the public to agree what level of investigation is appropriate and then [we want] measures in place to reduce the huge variation in the quality of autopsies.”

About 45% of deaths in England and Wales are referred to a coroner, who can request autopsies where deaths have been violent or unnatural, sudden, or of unknown cause or have occurred in prison or in circumstances requiring an inquest under other legislation. In 2005 22% of people who died were examined by a coronial autopsy.

A group of coroners and pathologists appointed by NCEPOD reviewed data on the autopsy process and reports that were returned by 121 of the 137 (88%) coronial jurisdictions included in the audit. A total of 1961 reports were reviewed. The subjects of the reports ranged in age from three days to 101 years.

The group found a quarter (436) of the 1691 reports to be poor or unacceptable because they lacked a good case history or because the autopsies lacked comprehensive external examination of the body, complete internal examination, or the taking of appropriate samples for further analysis.

The group considered that in 18% of the reports the stated cause of death was questionable because “it did not take appropriate account of the clinical course and autopsy findings.” The commonest problem was listing cardiac hypertrophy as the cause of death without appropriate investigations.

The report also found wide variations in practice. In a third of mortuaries the pathologist did not necessarily inspect the body before the anatomical pathology technologist began to open it and remove the organs. The brain was not examined in 14% of cases.

Possible reasons for the range in the quality of autopsy examinations included poor communication between coroners and pathologists, with gaps in the information that pathologists were given, and the small payment for coronial autopsies. Several pathologists and coroners taking part in the review said that the fee for a standard autopsy, £87.70 (€130; $163), “undervalued the autopsy and placed time pressures on pathologists, which limited the benefit of the autopsy.”

The review found less histopathological examination (removing organs and tissues for detailed analysis) than in NCEPOD reports in the past on postoperative autopsies. It suggested several reasons for the lower likelihood, including cost, not needing to carry out this type of examination if an acceptable medical cause of death could be stated (even if this was not the accurate cause of death), and the workload associated with having to communicate with next of kin to ask permission to remove and retain tissues. The report considered the trend important, because a higher proportion of autopsy reports where histology samples were taken were rated as good or excellent.

To improve the quality of coronial autopsies NCEPOD has recommended the introduction of nationally uniform criteria and standards for the investigation of reported deaths, detailing what should be included in an autopsy. These requirements include examining a body before evisceration to confirm identity and to observe any external features that might modify the process of examination and in most cases performing a complete autopsy with examination of all organs, including the brain. The report also called for national standards on the retention of organs and tissues and histopathology.

Causes of death should be investigated and recorded more accurately, the report recommends. In particular, sudden and unexpected deaths that may be related to cardiomyopathy and arrhythmias and deaths that may be associated with epilepsy should be investigated properly. Medical procedures that have contributed to a death should be included in the cause of death sequence rather than simply being recorded as pre-existing conditions.

Professor Lucas said that more medical input into the decision on whether to perform an autopsy would help direct pathologists in the level of investigation needed in each case. Coroners are generally solicitors so take decisions on a legal basis—one of the factors that Professor Lucas considered contributed to the lack of information currently provided to pathologists.

Legislation is being developed to change the structure of the coroners system in England and Wales, and a draft bill will be published in June. Professor Lucas hoped that the NCEPOD study would be used to inform these changes.