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NCEPOD has reviewed a medical process - the coronial autopsy - which affects more than one fifth of the population when they die. This process has not been reviewed on this scale and in this systematic way before, and the conclusions are evidence-based. A significant proportion of the process is well done in terms of the quality of the autopsy reports, but it is imperative that improvements be made so that the service becomes high quality. It is evident that the coronial system, as presently constituted, cannot bear many of the expectations placed upon it.
The recommendations, if implemented, will effect positive changes for the coronial system, the pathologists working within it, and bereaved families. Since about half of all deaths referred to a coroner result in an autopsy, these changes are central to any reform of the whole system. Public money is going to continue being spent on the investigation of death, and probably the total costs will increase. The public deserves value for money.
Reform requires a consideration of the purpose for which these autopsies are performed, as well as an overhaul of the whole system, with the introduction of audit and accountability. The incorporation of pathology training needs to be more formally addressed since this is critical for future practice. Such changes involve a national debate among all the interested parties and will necessitate statutory requirements: fundamentally, what level of quality in the coronial autopsy service does the public want? Is it right that the coroner's autopsy should have a broader purpose than at present and, in effect, take over the role of the consented hospital autopsy? If so, can the system be made to work efficiently if there is not a single system of oversight to replace the present disparate and fragmented operations? Is the public willing to accept the necessity for autopsy as a means of audit, research and teaching? And what is the public prepared to pay for this through taxation? Improvements to health and other services usually cost money, and the recommendations in this report, which particularly imply more time spent on each case by a pathologist, have resource implications.
Reform of the coronial system is promised. NCEPOD hope that this report will be widely
read and make a significant contribution to the debates that will ensue with the passage of legislation through Parliament. It is critical that the broadest possible discussions take place as death affects all families.
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