The (possible) Future of Autopsy Dr R Hadden Consultant Pathologist Derriford Hospital Plymouth
How has the Autopsy changed in the 21 st Century? Public Coroner Pathologist
The Anatomy Lesson of Dr. Nicolaes Tulp - 1632
The Anatomy Lesson of Dr. Deijman - 1656
• 101, 900 44% of reported deaths Coroners Statistics 2010 England Wales Ministry of Justice Statistics bulletin
• 89, 206 (-1% on 2014) • 38%
Pathologist • Variable Quality and limited quality control – The Coroner’s Autopsy: Do we deserve better? 2006 • Poor-unacceptable in 26% • Human Tissues Act • Diminishing workforce + under funding • RCPath – Certificate of Higher Autopsy Training – Optional post-ST 2 – Published Standards – CT autopsy • Hutton Review
Coroner • Coroners and Justice Bill 2009 • Chief Coroner • Coroners must be legally qualified +/- medical • Introduction of Medical Examiner System
Public • Bristol • Alderhey • Faith communities
Medical Examiners • Recommended by The Shipman Inquiry, Francis Report (2013), Kirkup Report (2015), Hutton review (2015) !! 8 1 0 2 il r • Robust scrutiny of circumstances and cause of death in all apparently natural deaths (i. e. those not investigated by the Coroner) p A • Improve quality of death certification in g in m o C • Offer relatives an opportunity to ask questions/raise concerns • Provide feedback for quality of care assurance systems • General medical advice to Coroners • Collate and share statistical information
Table 1: Initial aims of death certification reform • To ensure rapid referral to the coroner of any death where there are reasonable grounds to suspect that death may not be entirely due to natural causes • To avoid referral to the coroner of deaths where such referral is unnecessary • To provide a non-coronial route to certify deaths that are clearly due to natural causes, but where a doctor able to sign an MCCD is not available To improve the accuracy of certified causes of death • • To collect and report information on clinical governance issues identified during scrutiny • To ask the next of kin whether they had any concerns about the death that might justify further action (subsequently referred to as ‘The Shipman Question’) • To answer questions from the next of kin • To educate health service staff in matters relating to death certification
Effect on Coronial proceedings • Slight increase in inquests (approx. 5%), following scrutiny • Total deaths referred remained static, or showed a slight reduction. – Due to filtering of inappropriate referrals • Non-coronial route of certification when coroner believes death due to natural causes but no doctor qualified to complete MCCD.
Hutton Review • Meant to review the forensic service • Ended up encompassing coronial service • Too many mortuaries not enough pathologists (in the future) • Centralisation of death investigation (15 centres, previously 30 centres) – National Death Investigation Service – ? establish a Special Health Authority • Lead by Forensic pathologists • To become part of NHS work?
CT Autopsy • Joint statement by the RCR and RCPath • Validated, including angiography for IHD + PE Lancet. 2012 Jan 14; 379(9811): 136 -42 • 2015 Legal precedent for requesting CT in place of invasive PM (with understanding that invasive may still be needed)
Images from Ian Roberts’ Presentation: Imaging Techniques and cardiac autopsy
CT Autopsy • Who reports? • Where and with what resources? • Who pays? • Logistics (body transport, scanning, return to autopsy centre? )
CT Autopsy • Radiologists trained in autopsy CT • Pathologists make final decision on COD +/autopsy • Proposed regional centres (SW potentially in Bristol!) • Privately funded centres or use of NHS resources out of hours • Paid for by charities/family or local authority – Costs several hundred pounds vs £ 96. 80 for standard PM
So What is The Future? ! • Uncertain • Both RCPath and Hutton expect fewer autopsy pathologists in next few years • Centralised mortuaries, with dedicated CT scanners lead by forensic pathologists with a team of coronial pathologists working as part of the NHS! • Medical examiners scrutinising all non-coronial deaths ? More appropriate coroners referrals
Probable outcome: • Minimal changes • Decrease in autopsy rate following introduction of medical examiner • CT a long way off, until someone makes it cheaper than an invasive autopsy and gives us a scanner
Links: • Hutton Review • BAFM response to Hutton Review • RCR/RCPath Statement • The Hutton Review of Forensic Pathology, Imaging-based Autopsies and the Future of the Coronial Autopsy Service – A Commentary • Reforming death certification: Introducing scrutiny by Medical Examiners Lessons from the pilots of the reforms set out in the Coroners and Justice Act 2009
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