NCEPOD operates under the umbrella of the National Patient Safety Agency (NPSA) as an independent confidential enquiry. The main aim of NCEPOD is to improve the quality and safety of patient care and review of autopsy reports has been a core part of previous NCEPOD studies of deaths following medical and surgical interventions.

Following a proposal from the Royal College of Pathologists, NCEPOD has reviewed, in detail, the autopsy reports produced for the coroners; this includes both deaths in hospitals and in the community. This report is timely. There has never been a comprehensive review of the autopsy process and reports of deaths at the request of coroners. It is the first time that NCEPOD has requested data directly from coroners and we were delighted to obtain such a positive response with 88% (121/137) of all coronial jurisdictions contributing data. We are very grateful to all those who submitted data and to those coroners and pathologists who took part as advisors.

Because of increasing disquiet with fitness for purpose of the coronial system, legislation is now being prepared to change the structure of the system. NCEPOD hopes that the results and conclusions of this study will be a major contribution to the discussion over changes to the coronial system.

Professor T Treasure
NCEPOD Chairman