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| n = number of cases where information was provided |
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| Recommendations |
The operative procedure should be included in the cause of death statement.
Post-procedure deaths (i.e. those occurring during or within 24 hours of anaesthesia or sedation or those where it is known that the procedure is implicated in the death) should be reported to the coroner.
Pathologists should think more carefully about all the clinical circumstances of a death,
to produce an autopsy report more useful for clinical governance and audit.
NCEPOD supports the reforms of the coronial system and death certification, which will result in better scrutiny of deaths. |
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