Organs and autopsies

A while ago I talked about the latest Royal College of Pathologists Bulletin, and mentioned two things in that were particularly interesting. One was training and the second was coronial autopsies (page 13 if you can get hold of a copy). This article by Dr Peter Cowling, discusses the latest NCEPOD report (and its launch at the RCPath) which I’ve also talked about before.

One of the main points made both in the report and in the article is that the function of the coronial autopsy is not well defined. I think part of the problem is that as medics we see the autopsy as a medical procedure, whilst the majority of coroners are not medically qualified and to them is it the legal aspects that are important. At its most basic the legal function of a coronial autopsy is to exclude an unnatural cause of death and this (in combination with the new Human Tissue Act and coroners’ rules) leads to the situation where, as soon as a plausible cause of death is identified, the autopsy is stopped and no histology, toxicology or microbiology etc is usually done. This occurs in the jurisdiction of some (the minority I think), but luckily not all, coroners. No toxicology? Remember Harold Shipman? As a medical procedure this practice is unacceptable. The RCPath position as stated in the article is:

‘post-mortem examinations should be performed to the highest standards possible, to answer the needs of relatives and to serve the public health through improved national mortality statistics’

After reading a paper referenced by this article (Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study. Full text available free) I would add ‘providing feedback to the clinicians treating the patient’ to these functions. Historically this was one of the main functions of the autopsy – in the past the autopsy room would have been full of doctors seeking to learn and improve their practice. Now it is almost deserted and this function has been sidelined. The rate of consented (non-coronial) autopsies has declined dramatically recently.

The paper above looks at patients dying in an intensive care unit. They reviewed 38 cases which is not a huge number but considering the low and declining number of autopsies is not surprising. 39% of the cases had a major diagnosis missed before death, although the missed diagnosis may not have had an impact on the patient’s survival.

I’m sure all of us trainee pathologists have heard consultants say that a third of death certificates are wrong, something also mentioned in the NCEPOD report, hardly a good thing for mortality statistics. If finding a plausible cause of death and then stopping the autopsy is also occurring then this is likely to reduce the accuracy of the cause of death in some autopsied cases. So falling autopsy rates and the poor standard of some autopsies is likely to have a negative impact on mortality statistics.

As for answering the needs of relatives, as the RCPath article says, we don’t know what the relatives or the public want from autopsies. Maybe they don’t care at all about autopsies, is this the reason for the results of the NCEPOD study sinking without trace in the media? I don’t think is entirely true; autopsies were never out of the news during the organ retention scandal. So what do the public think of autopsies now? Do they know why autopsies are important, what the uses of the autopsy are and the potential consequences of badly done autopsies? Do they understand how the Human Tissue Act and coroners’ attitudes to autopsy histology (partly in reaction to the organ retention scandal) make medical investigation of deaths difficult and the implications of this? I doubt it. A browse through the RCPath guidelines on autopsy practice shows why histology is so important as a component of the autopsy, including in relation to cardiac deaths, where the heart may need to be retained for specialist examination to assess any genetic problems that might affect other family members.

During the NCEPOD report launch, Professor Peter Furness talked about some of these problems and wondered if the next ‘organ retention scandal’ would be failure to retain important organs for further examination. In the past we had headlines like ‘Doctors stole my son’s heart’. Will we have ‘Doctors threw away my son’s heart’ in the future?