Back into the mortuary

Well the NCEPOD report into coronial autopsies seemed to create little more than a ripple before vanishing from public view. Autopsies are only interesting if people think they are something out of a horror film and produce headlines like ‘Doctors stole my relative’s insides’. When we want to talk about what autopsies are really for and how they can be improved apparently hardly anybody is interested.

In the report the very important question was raised: ‘what is the purpose of the coronial autopsy?’ and a few possible answers were suggested. The most contentious aspect of the autopsy is the retention of tissue or organs, something that a lot of people believe is unnecessary. In many coroner’s jurisdictions the directions given to pathologists are restrictive. Some are told that no tissue, organs or fluid samples (for tests such as toxicology) can be retained in cases of natural death, or they can be retained only if no acceptable cause of death can be determined otherwise. This is not necessarily an accurate cause of death, just a reasonably plausible one.

Interestingly, very little research has been done into the use of histology as a postmortem investigation. This is probably because in the past it has been an integral part of the autopsy itself. If we received a surgical specimen, for example a mastectomy specimen containing a breast carcinoma, there would be uproar (and a pathologist before the GMC, probably) if we had a look at it, dissected it, and then got rid of it without making and examining a set of slides under the microscope. Without the microscopic examination of the specimen we have not done our job properly, the diagnosis is inaccurate and incomplete, the tumour cannot be typed and graded and the patient cannot get an accurate assessment of their likely prognosis and best treatment options.

But at autopsy, suddenly the tables have been turned and we are now frequently forced to rely on a naked eye examination only. For many relatively common autopsy diagnoses this is not such a big problem – the ruptured aortic aneurysm and massive subarachnoid haemorrhage are easy enough to spot. For others our ability to diagnose them without histology is in doubt; the common cause of death that is pneumonia is a case in point.

So what is the point of the coronial autopsy? Are we expected to make an accurate assessment of the cause of death, because if so our hands are already tied by restrictions on our practice. Or are we only expected to exclude foul play (without a toxicological analysis?) and produce our best guess as to the cause of death.

What it seems to boil down to is the question: is the coronial autopsy a medical or a legal procedure?