Principal recommendations

Government should consider and agree the fundamental purposes of the coronial autopsy. An ideal opportunity exists to do this during the passage through Parliament of the Bill for reform of the coroner's system as recently announced.

There should be nationally uniform criteria and standards for investigation of reported deaths. This includes the diagnostic level of investigation at autopsy and the definition of what a postmortem examination comprises.

There should be regular (independent) peer review of coronial autopsy reports and processes to maintain consistency of agreed standards and accountability, and all pathologists and coroners - in training and as continuing professional development - should review the autopsy reports and related documents of their peers.

Information available to pathologist prior to autopsy

Specific written requests for investigations, made by a coroner, should be followed, or an account rendered in the autopsy report as to why this was not addressed.

The information provided by coroners' offices to pathologists should be in a standardised format that includes an agreed minimum clinical and scene of death dataset, including date of birth and occupation of deceased. Such information should be communicated in writing.

Case history

A clinical and case history should be included in an autopsy report and should state the provenance of the information.

External examination

The height and weight should both be measured, the BMI calculated, and the data given in the report.

In all deaths, the report must clearly document external injuries or the absence of such injuries.

Evisceration of bodies

Before evisceration of a body, the pathologist must inspect the body first. This is to confirm identity, to observe any external features that might modify the process of examination and to consider the possible need for a forensic examination.

Internal examination

Normally a complete autopsy should be performed, with all organs including the brain examined. Limited autopsies - upon request - should be carefully considered on a case by case basis and when complete examination is essential to determine the cause of death the pathologist must insist upon that. If an organ system is not examined, consideration and account should be made of the potential information lost, in the context of the deceased's clinical pathology.

Decomposed bodies should be thoroughly examined (i.e. external and internal examinations) to identify significant injuries, primary pathologies and comorbidities, and toxicology should be performed as appropriate.

Tissue retention

Autopsy reports must clearly indicate whether or not tissues were retained, and what they comprise, if retained.

There should be national criteria and standards on organ and tissue retention for histopathology in coronial autopsies, in order to provide convincing evidence of the cause of death.

Deaths in persons known or suspected to abuse alcohol and/or cases associated with drug toxicity should be properly investigated.

Causes of death

Sudden unexpected deaths suspected to be related to cardiomyopathy and arrhythmias (i.e. SADS) should be investigated according to best practice autopsy guidelines.

Deaths suspected to be related to epilepsy should be investigated properly, according to the Department of Health National Service Framework for Mental Health action plan: "Improving services for people with epilepsy".

Deaths following medical interventions and complications require detailed investigation and consideration, and should not be summarised merely as (e.g.) 'ischaemic heart disease' or other underlying comorbidity. If the procedure contributed to the death, then this should be indicated in the cause of death sequence.

Clinicopathological correlation

There should be a clinicopathological correlation in each report that reviews the case and robustness of the conclusions based on the available evidence.

The mortuary

Pathologists should wear protective clothing over appropriate scrub suits, not over their day clothes.

All mortuaries should be quality accredited.

The approach to infectious disease management in mortuaries should be reviewed and standardised.