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The (possible) Future of Autopsy Dr R Hadden Consultant Pathologist Derriford Hospital Plymouth 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 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. Nicolaes Tulp - 1632

The Anatomy Lesson of Dr. Deijman - 1656 The Anatomy Lesson of Dr. Deijman - 1656

 • 101, 900 44% of reported deaths Coroners Statistics 2010 England Wales Ministry • 101, 900 44% of reported deaths Coroners Statistics 2010 England Wales Ministry of Justice Statistics bulletin

 • 89, 206 (-1% on 2014) • 38% • 89, 206 (-1% on 2014) • 38%

Pathologist • Variable Quality and limited quality control – The Coroner’s Autopsy: Do we 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 Coroner • Coroners and Justice Bill 2009 • Chief Coroner • Coroners must be legally qualified +/- medical • Introduction of Medical Examiner System

Public • Bristol • Alderhey • Faith communities Public • Bristol • Alderhey • Faith communities

Medical Examiners • Recommended by The Shipman Inquiry, Francis Report (2013), Kirkup Report (2015), 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 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 • 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 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 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 Images from Ian Roberts’ Presentation: Imaging Techniques and cardiac autopsy

CT Autopsy • Who reports? • Where and with what resources? • Who pays? 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 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 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 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 • 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