Post–Mortem Potential

I don’t think it is overstating things to say that there is a crisis in the provision of post-mortem services in the United Kingdom. Almost all post-mortems performed are for the Coroner, with very few hospital or consented examinations taking place. Coroners are increasingly finding it difficult to get their post-mortem examinations done, as pathologists are in short supply these days and must concentrate on diagnostic work for the living.

A recent report on forensic pathology and coronial post-mortems (1) sets out the current challenges. But it’s getting worse. My hope is that we can develop a new national service for the investigation of deaths, as the report recommends. Unfortunately, three different government departments – Justice, Health, and the Home Office – are involved, so coordination is complex. The Royal College of Pathologists is working with all of the agencies involved to try to find a solution.

What surprised me most when I began practicing pathology was how little understanding many of my clinical colleagues have about the work we do. It’s not unusual for a consultant to fail to request a post-mortem on a patient because they truly believe there is nothing new to learn. Educating service users about the role of pathology and the value of the post-mortem examination remains a major challenge.

The changing face of death investigation

A national system of medical examiners (MEs) was proposed in the UK in 2005. MEs are experienced doctors who can scrutinize and confirm the cause of all deaths that do not fall under the coroner’s jurisdiction – but they don’t have to be specialist post-mortem pathologists; they can come from any specialty. Unexpectedly, it has taken – and, in fact, is still taking – much longer than anticipated to introduce MEs across the country. Although the legislation was passed in 2009, progress since then has been slow.

In 2016, the Secretary of State for Health announced that MEs would be introduced in April of 2018. At that point, a consultation exercise was undertaken – but we are still awaiting the outcome of that exercise, and the implementation date has been further postponed to 2019. The College, which is the lead organization for the recruitment and training of MEs, has campaigned for many years for their introduction and believes that they will make significant contributions to improving the accuracy of death certification, collecting data to inform health policy, and improving the quality of care for patients.

The introduction of the Human Tissue Act in 2006 is another factor that can affect death investigation. The Act brought about much tighter regulation of the removal, use and storage of human tissue in England, Northern Ireland and Wales. The new regulations, which apply to any material from the human body that includes cells (including bodily waste), made it an offence to remove, store or use tissue without appropriate consent. Premises where human tissue is used now need a license for treatment, research, post-mortems, anatomical examination and public display. There are penalties of up to three years’ imprisonment for failing to obtain appropriate consent for the use of tissue or storing tissue without a licence. Although pathologists recognized the need to update previous legislation, there were significant concerns about the bureaucratic burden and expense of implementing the act and the detrimental effect on research.

With the strengthened regulations for handling human samples, the forthcoming introduction of medical examiners, and potential future changes to forensic pathology and post-mortem examinations, we are hoping to overhaul the UK’s system of death investigation for the benefit of our patients – both past and future – and their families.