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The main factors that determined the quality assessment in the opinion of the majority of the advisors were those that have been documented in the results of this study:
- a good case history in the autopsy report;
- comprehensive external examination of the body;
- comprehensive and complete internal examination;
- taking samples for further analysis as appropriate to the case;
- providing a clinicopathological correlation that explains the death and what led up to it;
- giving a cause of death that corresponds with the case history and the findings at autopsy.
These are all factors that previous NCEPOD reports have emphasised, and in those and in the present study, the undue brevity of many reports was noted and criticised.
There was a wide range of report styles and lengths, from short one page bullet point reports to multi-page documents full of detail and evidence of much thought going into the production. Since the more synoptic reports lacked several of the elements that the advisors considered to be important, these were more likely to be graded as less than satisfactory. The overwhelming impression conveyed from reading the nearly 1,700 autopsy reports in this dataset was of the variation in attitude of the pathologists to the job in hand. At one extreme are the one page perfunctory reports that provide a cause of death without any case history,
detail regarding the autopsy examination, or any correlation of known pre-mortem events. As indicated in the results, some of these were considered by the advisors to be misleading and possibly incorrect in even excluding unnatural death.
At the other extreme there were a number of autopsy reports graded as 'excellent' which showed how carefully the pathologist had considered the case and attempted to resolve all the issues raised by the death. All these reports included the critical clinicopathological correlation. The use of histopathology was variable. There were undoubtedly some cases where histopathology was not done and should have been.
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