THE REFORM OF THE CORONER AND DEATH CERTIFICATION SERVICE

Under the proposed new ‘Coroner and Death Certification System’¹², all deaths – whether
in the community or hospital – will be reported to and scrutinised by a medically qualified medical examiner (ME), who will consult with the certifying clinician on the cause of death.
If the ME considers that further investigation, including autopsy, is required, there will be consultation with the regional coroner.

The criteria for authorising an autopsy will probably remain similar to those currently operating, but it is intended that there be more national consistency in the proportion of cases resulting in autopsy and in the scope of those examinations. A positive intention is
to facilitate the better use of post-mortem medical examinations in clinical governance, including mortality audit.

The ME will advise on the minimum level of invasiveness of autopsies, including possibly
the use of magnetic resonance imaging (MRI) evaluation in place of standard dissection and organ examination. Unless and until the use of MRI is properly validated, this has serious implications for the value of autopsies in future NCEPOD studies since it is not evident that MRI technology is as sensitive as open examination in determining the circumstances of post-intervention deaths¹³. The usefulness of MRI in evaluating perioperative deaths, as opposed to deaths in the community, is so far unexplored and it may be that the current capacity of MRI machines could not cope.

Another potentially detrimental aspect of the proposed reforms of the coronial system is further pressure not to take organs and tissue samples for histopathology. As paragraph 67 of the position paper states¹², ‘retention should only take place where absolutely necessary’ (our emphasis). It is the view of NCEPOD that this will necessarily inhibit pathologists further in seeking to investigate post-intervention deaths fully, since there is already no uniformity and clarity about taking histopathology samples. The results will not be to the benefit of clinical governance and, ultimately, of the public.

A new position, that of Medical Adviser to the Chief Coroner, is proposed under the coronial system reform, and that person should have a significant influence upon the national standards of autopsy performance.

It is important for pathological organisations in the UK to continue to emphasise
and publicise the significance and benefits to the families and to the medical profession
of the well-performed and reported autopsy in the audit and improvement of standards of medical care. This is a view that NCEPOD has consistently held since its inception. In the current medico-political climate, there is intended to be a reduction in the proportion of deaths that eventuate in an autopsy – England & Wales has a significantly higher overall autopsy rate than countries with comparable medico-legal systems⁷. If this reduction is inevitable, it is important that the autopsy firstly is focussed on those cases where the information will be the most useful, particularly those following medical interventions,
and secondly is performed well and to measurable quality standards.