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The advisors for this study were drawn from interested pathologists and coroners, who may be presumed to be more than averagely concerned about the quality of the coronial autopsy as they applied to help NCEPOD with this study. The standards they were using were based on best practice guidelines which, in turn, were drawn up by a professional body that had reviewed all existing guidelines (including those in other countries). Thus the advisors' set point for quality would be that the autopsies and their reports that did not reach somewhere between levels B1-B2 in the previous list would be deemed unsatisfactory. In 18% (310/1,691) of the cases in the study, the cause of death did not take into appropriate account the clinical course and autopsy findings as presented in the report and in the supporting documentation; that is unsatisfactory. The fact that the majority of cases did reach that point as assessed from the paperwork indicates that there is a basic body of quality. Nonetheless it has to be acknowledged that reading the paperwork of an autopsy is not the same thing as assessing what really happened in the mortuary, nor whether the findings and cause of death are, in an absolute sense, true. Autopsy work is unusual in that, unlike surgical procedures, there are usually no peer observers present. There may be trainees, and there will be one or more anatomical pathology technologists in the mortuary, but uncommonly is there a peer pathologist who might criticise the examination and question the conclusions derived from them. The coroner, who is usually only legally trained, is obliged to take the autopsy report at face value if it presents a natural cause of death and there are no features to lead the coroner to suspect that the death was 'unnatural'.
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