Bulletin October 2017 Number 180

Chair of the College's Death Investigation Group Mike Osborn on the pressures on staffing, funding and expertise in post-mortems.

Background

Death investigation, in the form of non-forensic post-mortem practice, has long been a part of routine histopathology work for many consultants. Although generally a small part of these consultants’ practice, this work carries, or is at least perceived to carry, a high risk in terms of reputation and possible legal action. To help alleviate this, and in line with other areas of practice, the College has long produced guidance to members relating to post-mortem-related activities. 

The College has undertaken a detailed review of the various guidance documents over several years; however, in undertaking these updates, a variety of changes in the landscape of death investigation and non-forensic post-mortem practice became clear.

The demise of the non-coronial consented post-mortem and the relative increase in the number of coronial post-mortems, combined with reduced numbers of post-mortem-active pathologists and conflict between NHS and coronial workload pressures, has led to problems with the provision of the coronial non-forensic post-mortem service.

The Coroners and Justice Act 2009 provided the primary legislation for the introduction of medical examiners,1 which it was hoped would help reduce the number of coronial post-mortems needed in the UK. However, pilot studies have shown conflicting evidence, with some suggesting that the new system may in fact lead to an increase in this area of work.

Post-mortem training, in the context of general histopathology training, was made optional in 2010 to try to improve the quality of training and assessment. A standalone training module covering non-forensic post-mortem practice, together with the provision of a specialised examination – the Certificate of Higher Autopsy Training (CHAT) – were developed to fill the training and assessment needs this created.

The Hutton review of forensic pathology,2 which also included non-forensic post-mortem work, made many recommendations regarding the future of the non-forensic post-mortem service, none of which have been implemented. Difficulties with service provision have, if anything, worsened in many parts of the country in the last few years, with several examples of regions being unable to deliver a timely service, increasing numbers of established post-mortem pathologists giving up post-mortem work and non-forensic post-mortem pathologists being pressured into undertaking cases that should be handled by forensic pathologists. In addition, every element of the system is under intense budgetary pressure.

Given these changes, and the need for the College to provide guidance in these and other related areas as well as in relation to specific non-forensic post-mortem scenarios, the Trustee Board of the College agreed the expansion of the remit of the Death Investigation Group in December 2016. It changed from what had previously been a virtual, email-based group used to provide ad-hoc advice on non-forensic post-mortem issues into a fully functioning College committee holding regular meetings and acting as a focus for advocacy relating to all aspects of non-forensic post-mortem work.

Remit

The Death Investigation Group oversees the delivery of the responsibilities of the College in all matters relating to investigation of non-suspicious deaths in the UK. Its advice and guidance relates to non-forensic (non-suspicious) post-mortems, be they conducted with consent (i.e. hospital post-mortems) or for the coroner. Investigation of suspicious deaths does not fall under the remit of the group.

Membership and function

The Death Investigation Group includes representatives from all College specialities that may be involved in the investigation of a non-suspicious death, including forensic pathology and toxicology. In addition, other stakeholder groups both from within and outside the College are represented, including medical examiners, coroners, the Chief Coroner, the Human Tissue Authority and the Association of Anatomical Pathology Technology. Any guidance produced by the group is circulated prior to full College consultation to all these members, and through them to their own groups and organisations as well as to the College Lay Governance Group and any other College bodies as necessary. The group itself reports direct to the College council. They meet in person twice a year but interact through email as necessary.

Main areas of activity

Post-mortem guidelines

The group produces guidelines specifically for non-suspicious deaths. This guidance does not aim (nor claim) to cover deaths that are deemed in any way suspicious by the police or any other investigating organisation. Guidelines relating to suspicious deaths are not the remit of the Death Investigation Group and are produced by other relevant specialist groups within and outside the College.

The guidelines the Death Investigation Group produce aim to set a standard at the level that would be expected of a consultant pathologist conducting a routine coronial non-forensic post-mortem on a non-suspicious death. The level of this guidance takes into account the facilities, funding and logistical support currently available generally within the coronial post-mortem service. Specific and particular areas requiring guidance for procedures that are deemed beyond those expected of a such a routine coronial post-mortem are added as appendices to the final guidelines so as to be available if needed, for example in the case of a consented hospital post-mortem where further complex investigations have been requested. Such appendices are not considered to represent part of the standard guidelines. The level at which these guidelines are set has been chosen to represent the best service that can reasonably be expected to be provided to the public (for the most part through the coroner service), taking into account the constraints imposed upon that service by its governing bodies. 

The areas covered by the guidelines reflect those that have been raised as areas of concern or requested by members. Production of these guidelines is dependent on College members volunteering to be authors. With the help of the College they produce draft guidance that is then circulated to the Death Investigation Group and through them to their associates. Following their input, any necessary changes are made by the authors and the draft sent out for formal full College consultation. Any further changes needed are then made by the authors and the final document published by the College. Production of these guidelines is therefore dependent on authors volunteering for the role and we are extremely grateful to all who take on this responsibility. Where possible, well-recognised experts in a field are asked to help produce the guidelines relating to their field of expertise. This is, however, not always possible or practical. In some areas, opinions vary as to what practice should be and there are some contentious issues. As a result, on occasion such areas of disagreement have led to robust feedback in the consultation stages and to heated debate between members. The various aspects of the consultation process, first through the Death Investigation Group and their associates and then through full membership formal consultation, aim to address this issue and to facilitate publication of a final document that is of a high standard providing robust, pragmatic and useful guidelines to College members.

Investigation of unnatural deaths

While the remit of the Death Investigation Group is restricted to non-forensic work relating to the investigation of non-suspicious deaths, most pathologists working in this field will often be asked to conduct non-forensic post-mortems on deaths which are, although not suspicious, clearly not natural (e.g. hanging, drowning and those related to drug use or road traffic deaths). This area of work is extremely contentious and is the area in which many non-forensic pathologists feel the most ill at ease. Many, both inside and outside the profession, believe that all such non-natural deaths should be examined by a forensic pathologist, or similar professional, as occurs in many other countries. Indeed, some point out that any death, even those deemed non-suspicious by the police or other investigating organisations, can turn out to be suspicious and therefore all coronial post-mortems should be conducted by a forensic pathologist and investigated as if they were a suspicious death. Others, however, feel that a non-forensic pathologist competent in post-mortem practice is more than capable ofdealing with such cases. Both arguments are valid. However, as Dr Suzy Lishman, President of the College, has said: ‘Whatever the arguments about whether all such autopsies should be done by forensic pathologists, the fact is that the funding isn’t available and many general pathologists will be asked to do these types of autopsy by the coroner. We need pragmatic guidelines to reflect what happens in the real world (which includes guidance on which cases need a forensic PM).’ With this in mind, the Death Investigation Group is working to develop guidelines on these areas of concern, including drowning, hanging and drug-related deaths. In addition, the group is working with the Home Office, police and forensic pathologists to produce a guidance document setting out which cases should only be done by a forensic pathologist. 

Audit of post-mortem practice

Most post-mortem practice now is coronial work. The 2006 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) audit into coronial post-mortems showed that over a quarter were of poor or unacceptable quality. In addition, the report recommended regular peer review of autopsy reports,3 as already occurs in forensic practice. Despite this, no audit or external quality assessment (EQA) scheme exists for non-forensic autopsy practice. The possibility of developing such an EQA or audit system has been discussed by the Death Investigation Group and two possible methods were suggested. The first, consisting of slides or virtual slides and images being circulated, as for a standard histopathology EQA, has proponents, but is felt to be somewhat expensive and difficult to organise. The second, review of reports by peers as per the NCEPOD methodology, seems a suitable method. The Death Investigation Group has investigated this possibility but feels that, although it would be a useful exercise fully supported by the group and College, the current climate in coronial post-mortem services – including the issues with workforce, fee structure, funding and support – does not make it feasible, particularly given that most other EQAs are funded by the employers of the pathologists involved, a situation unlikely to happen for non-NHS coronial work, which coroners themselves are unlikely to finance.

Remuneration and funding

The standard fee for conducting a routine non-forensic coronial post-mortem is £96.80. Many, including the Death Investigation Group, regard this level of remuneration as extremely low and in no way reflective of the complexity and workload of such a case, however routine it may be. In addition, this low level of remuneration is in no way reflective of the responsibility taken on by the pathologist when doing such a case. This low-fee structure together with other funding strains on the non-forensic post-mortem service are major contributors to the lack of post-mortem-active pathologists in England and Wales – a factor that was highlighted in the Hutton report. The Death Investigation Group are working hard to champion this issue and find ways to address it, particularly through their links with the Chief Coroner and the Coroner’s Society, both of whom are represented on the group. It is, however, an uphill struggle given the current financial circumstances of the country generally.

Lack of post-mortem pathologists

The College is often contacted about, and regularly blamed for, the lack of post-mortem-active pathologists available to conduct non-forensic post-mortems. This is a situation that appears to have markedly deteriorated over the last five years. The cause of this deficit is multifactorial. Lack of remuneration is a major issue already touched upon. Other factors too play a role, particularly a lack of support by some NHS departments towards those wishing to provide a post-mortem service, an understandable position given the extreme service pressures most NHS departments currently face. The Death Investigation Group and its associates are currently collating accurate information on this lack of pathologists, and the regions most severely affected by it. They are also working to identify and quantify the underlying causes for the shortage. This accurate information will provide invaluable evidence in the College’s efforts to lobby government to support the post-mortem service through workforce planning, service provision and adequate funding.

Your Death Investigation Group

The Death Investigation Group exists to help and advise College members, enabling them to provide the best service possible to the public. We are here to help you so please do contact us if you ever need advice on any non-forensic post-mortem-related issue, be that general advice, a specific question, a case you are unsure if you should take or a whole area for which you would like the College to produce guidance. We are also dependent on you, our College members, so please volunteer to write guidelines and do please provide feedback during the consultation phase of guideline development. 

If you would like to get in touch with the Death Investigation Group about these or any other i­ssues, please email us at the College at info@rcpath.org with “FAO DIG” in the subject section.

Dr Mike Osborn
Consultant Histopathologist 
Imperial College Healthcare NHS Trust

References

1    Coroners and Justice Act 2009.
http://www.legislation.gov.uk/ukpga/2009/25/pdfs/ukpga_20090025_en.pdf

2    Peter Hutton – review of forensic pathology in England and Wales.
www.gov.uk/government/publications/review-of-forensic-pathology-in-england-and-wales

3    NCEPOD – The Coroner’s Autopsy: Do we deserve better? (2006).
http://www.ncepod.org.uk/2006Report/Downloads/Coronial%20Autopsy%20Report%202006.pdf