1. The (possible) Future of Autopsy
Dr R Hadden
Consultant Pathologist
Derriford Hospital
Plymouth

2. How has the Autopsy changed in the 21st Century?
Public
Coroner
Pathologist

3. The Anatomy Lesson of Dr. Nicolaes Tulp - 1632

4. The Anatomy Lesson of Dr. Deijman - 1656

5. 101,900
101,900
44% of reported deaths
Coroners Statistics 2010 England and Wales Ministry of Justice Statistics bulletin

6. 89,206 (-1% on 2014)
38%

7. Pathologist Variable Quality and limited quality control
The Coroner’s Autopsy: Do we deserve better? 2006
Poor-unacceptable in 26%
Human Tissues Act
Diminishing workforce + under funding
RCPath – Certificate of Higher Autopsy Training
Optional post-ST2
Published Standards
CT autopsy
Hutton Review

8. Coroner Coroners and Justice Bill 2009 Chief Coroner
Coroners must be legally qualified +/- medical
Introduction of Medical Examiner System

9. Public
Bristol
Alderhey
Faith communities

10. Coming in April 2018!! Medical Examiners
Recommended by The Shipman Inquiry, Francis Report (2013), Kirkup Report (2015), Hutton review (2015)
Robust scrutiny of circumstances and cause of death in all apparently natural deaths (i.e. those not investigated by the Coroner)
Improve quality of death certification
Offer relatives an opportunity to ask questions/raise concerns
Provide feedback for quality of care assurance systems
General medical advice to Coroners
Collate and share statistical information
Coming in April 2018!!

11. Table 1: Initial aims of death certification reform
To ensure rapid referral to the coroner of any death where there are reasonable grounds to suspect that death may not be entirely due to natural causes
To avoid referral to the coroner of deaths where such referral is unnecessary
To provide a non-coronial route to certify deaths that are clearly due to natural causes, but where a doctor able to sign an MCCD is not available
To improve the accuracy of certified causes of death
To collect and report information on clinical governance issues identified during scrutiny
To ask the next of kin whether they had any concerns about the death that might justify further action (subsequently referred to as ‘The Shipman Question’)
To answer questions from the next of kin
To educate health service staff in matters relating to death certification

13. Effect on Coronial proceedings
Slight increase in inquests (approx. 5%), following scrutiny
Total deaths referred remained static, or showed a slight reduction.
Due to filtering of inappropriate referrals
Non-coronial route of certification when coroner believes death due to natural causes but no doctor qualified to complete MCCD.

14. Hutton Review Meant to review the forensic service
Ended up encompassing coronial service
Too many mortuaries not enough pathologists (in the future)
Centralisation of death investigation (15 centres, previously 30 centres)
National Death Investigation Service
?establish a Special Health Authority
Lead by Forensic pathologists
To become part of NHS work?

15. CT Autopsy Joint statement by the RCR and RCPath
Validated, including angiography for IHD + PE
Lancet Jan 14;379(9811):136-42
2015 Legal precedent for requesting CT in place of invasive PM (with understanding that invasive may still be needed)

16. Images from Ian Roberts’ Presentation: Imaging Techniques and cardiac autopsy

19. CT Autopsy Who reports? Where and with what resources? Who pays?
Logistics (body transport, scanning, return to autopsy centre?)

20. CT Autopsy Radiologists trained in autopsy CT
Pathologists make final decision on COD +/- autopsy
Proposed regional centres (SW potentially in Bristol!)
Privately funded centres or use of NHS resources out of hours
Paid for by charities/family or local authority
Costs several hundred pounds vs £96.80 for standard PM

22. So What is The Future?! Uncertain
Both RCPath and Hutton expect fewer autopsy pathologists in next few years
Centralised mortuaries, with dedicated CT scanners lead by forensic pathologists with a team of coronial pathologists working as part of the NHS!
Medical examiners scrutinising all non-coronial deaths ? More appropriate coroners referrals

24. Probable outcome:
Minimal changes
Decrease in autopsy rate following introduction of medical examiner
CT a long way off, until someone makes it cheaper than an invasive autopsy and gives us a scanner

25. Links:
Hutton Review
BAFM response to Hutton Review
RCR/RCPath Statement
The Hutton Review of Forensic Pathology, Imaging-based Autopsies and the Future of the Coronial Autopsy Service – A Commentary
Reforming death certification: Introducing scrutiny by Medical Examiners Lessons from the pilots of the reforms set out in the Coroners and Justice Act 2009