Written evidence from Dr Cordelia Howitt (Consultant Histopathologist); Dr Mark Stephens (Consultant Histopathologist); Dr Louise Edwards (Consultant Histopathologist); Dr Karthik Kalyanasundaram (Consultant Histopathologist), University Hospital North Midlands (Royal Stoke University hospital)
1. The extent of unevenness of Coroners services, including local failures, and the case for a National Coroners Service
- There seems to be great variation in practice between coroners with some coroners requesting hardly any coronial PMs and some allowing large numbers of ‘consent type’ cases to be undertaken under coronial jurisdiction. There is some experience of coroners asking clinicians to provide a cause of death on insufficient or limited evidence. Furthermore there is limited cooperation of some coroners to assist with investigation of underlying undiagnosed genetic conditions.
- There is great variation in the quality of PMs and currently there is no quality assurance scheme or CPD scheme for pathologists who carry out post-mortem work which could well lead to poor quality autopsies. Furthermore there is no department in the government within the health systems concerned with autopsy work and there is no minister who takes an interest in the area unless there is an apparent ‘scandal’ to reveal the shortcomings. Autopsies should be quality controlled: Some form of quality control should be implemented. Some preliminary thoughts are peer review of cases, EQA schemes, update training sessions for pathologists etc. National cancer screening programs have regular QA visits; could the same not be done for the autopsy service?
- More recently local authorities have developed an interest in post-mortem CT scanning. This is welcomed by communities, the coroner and some pathologists. However the CT autopsy should form part of the autopsy process and the limitations need to be recognised. More importantly to us is the need to recognise that it forms part of the investigation of death, limitations recognised and most importantly QC and CPD schemes for radiologists and pathologists. Currently there is no quality assurance or CPD scheme for radiologists and pathologists who report CT autopsies. There are anecdotal causes of death (by CT) that are inconsistent with the mode of death to a degree of absurdity. This could be improved by update training sessions for radiologists for CT autopsies. Quote from one of our pathologists: “I have been providing feedback to radiologists who are providing reports for our coroner’s cases but it appears that I am either the only one or one of the few offering such feedback. This has resulted in improvements of reports. The radiologists have been pleased to be involved in this dialogue. A more formal on-going training programme is required. CT autopsy assessment and reporting is different from CT reporting in life it is a fundamental error to equate the two.”
- Invasive autopsies should be undertaken in a proportion of CT autopsies in cases where there is a confident radiological assessment as a form of quality control of autopsy radiology reporting.
- The % of pathologists taking Histology at PMs varies greatly with some coroners simply not allowing taking any including cases where the pathologist requests authority to take histology. This will impact on the quality of the conclusions in such cases, which may have implications for medical and legal conclusions in a given case. Some pathologists do give into this pressure knowing that the outcome of the autopsy will be of limited value by not doing the necessary tests that are required for a full conclusion.
2. The Coroners Service’s capacity to deal properly with multiple deaths in public disasters
Please see response to Covid
3. Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths
Please see response to Covid
4. How the Coroners Service has dealt with COVID 19
- In our area autopsies in covid positive cases were avoided as far as possible, with covid 19 not being a sufficient reason to refer cases to the Coroner or for autopsies to be undertaken if autopsy CT was performed unless there were other reasons to proceed with autopsy. Whilst this serves the coronial requirements it missed an opportunity to gather potentially valuable data which could have been collected for public health purposes. This feeds in to point 3 i.e. the role of the coroner in the prevention of avoidable future deaths.
- So our suggestion is that in such situations: the Coroner’s service is well positioned to help facilitate the acquisition of valuable autopsy data in a large number of cases in a public health crisis. This may require a modification of the law but is all for the ‘public good’. This is not too dissimilar to issues related to dealing with multiple deaths in a public disaster.
5. Progress with training and guidance for Coroners
- The lack of medical knowledge of some coroners can have negative consequences due to lack of understanding of the medical context. It would be desirable for coroners to have some form of medical training.
6. Improvements in services for the bereaved
- Improvements in services for bereaved: The CT autopsy for community deaths and A&E cases should be extended: The CT guided autopsy has a role in limiting the number and extent of invasive autopsies in community deaths and A&E deaths. The pathologist who is trained in the investigation of death should oversee the case however and in our view it is a dangerous road to delegate this to the radiologist who is not trained in the investigation of death. This is analogous to the radiologist reporting to the surgeon who makes the decisions. The radiologist does not replace the surgeon.
- Autopsies should be performed as soon after death as feasible: There is often a significant delay between death and autopsy in my view. I realise that appropriate information needs collecting but a decrease in the interval between death and autopsy is desirable. It would: facilitate the funeral arrangements for the family, allow optimum preservation of organs and tissues for assessment esp. if ancillary tests are required and be likely to encourage trainees to undertake coronial autopsy practice (i.e. a delay in the interval between death and the post mortem will result in a variable degree of decomposition and a more unpleasant experience for all concerned.)
- Improvement in communication between coroners and relatives: The coroner’s office should ensure good lines of communication with relatives to regularly update them on progress in cases during the time between referral to the coroner’s service and conclusion of cases.
- Progress with training: Training of junior pathologists is key to maintaining service for the future. Any decrease in the invasive autopsy rate will adversely affect training. We also suggest that specific designated pathology trainers are identified to supervise training so as to ensure quality of training of trainees for the future.
- If the role of the CT in autopsies is extended this will limit the number of invasive autopsies performed and this will impact on the trainee pathologists and mortuary technicians. If technicians do not undertake the practical procedures of the autopsy this skill base will be attenuated.
- The ability of pathologists to accurately recognise macroscopic pathology will be impaired and may lead to erroneous conclusions. It will also impact on learning autopsy histology which will also potentially impact on the quality of service.
- We suggest that a proportion of CT autopsy cases be subject to a standard full invasive autopsy to maintain the training of both mortuary technicians and junior pathologists for the future. This should be directed and supervised from the centre via the senior coroner to maintain fairness across the country. This would also have the dual role in quality control as noted above.
- We suggest that trainee pathologists are given some training in coronial / inquest law and are called to inquests for training purposes (where they would not otherwise be called) so that they are better equipped to give evidence in more problematic cases.
- Fairness in the Coroners system
- Relatives don’t seem to be aware of the option to challenge a coroner’s verdict. In the case of Jeffrey Markham v HM Coroner Greater London (Western District) a family successfully changed the cause of death in crown court after genetic testing of the their deceased son revealed long QT syndrome. It is published on the CRY website with instructions how to do this at a minimal cost.