Candidates will be assessed on a post-mortem examination that they will perform at a designated centre. The autopsy case may be either a consented or coronial case, with the majority of cases being coronial.

The macroscopic component will be held over a single day for each candidate and there will be two examiners, who may be internal and/or external. Candidates who have either trained at the autopsy centre or who are resitting the macroscopic component, will invariably have oversight by an external examiner.

There are 3 parts to the macroscopic examination:

• Autopsy with presentation to examiners and write-up
• Brain dissection, histological sampling and macroscopic interpretation (including additional material such as photographic images, ‘pots’)
• Viva voce

In the course of their assessment, candidates must demonstrate to the examiners, at a level expected of someone who will soon be taking up a newly appointed consultant post in neuropathology, competence in the following:

• Assessment of clinical case records and the application of the clinical information to the conduct and interpretation of a post-mortem examination. This includes an understanding of the clinical questions raised by a death, and appropriate knowledge of general medicine, surgery and other relevant specialities.
• Presentation of the post-mortem findings in a straightforward manner to a non-medical coroner, to assist him/her to reach a verdict and cause of death in a medicolegal case.
• Communication with medical staff and relatives of the deceased.
• The ability to describe and work within the laws and guidelines that apply to the post-mortem examination.
• Demonstration of knowledge, skills and appropriate professional attitudes in the conduct of a post-mortem examination, including special autopsy techniques.
• Demonstration of familiarity with mortuary management.
• The ability to describe and work within health and safety guidance related to mortuaries and post-mortem examinations.
• Discussion of the clinical relevance and implications of the post-mortem examination.
• Demonstration of knowledge, skills and appropriate professional attitudes in the conduct of macroscopic and histological examination of fixed brains and spinal cords.
• Demonstration and knowledge of appropriate clinicopathological correlation, pathology and pathophysiology relevant to the autopsy, including general (non-nervous-system related) pathology, and to specialist nervous system examination.

The autopsy may have ether a neurological or general pathological focus, depending upon case availability. Candidates are not expected to perform a post-mortem examination on any of the following:

• Decomposed bodies
• Complex perioperative deaths with significant adhesions or multiple intestinal re-orientations
• High risk cases such as suspected transmissible spongiform encephalopathy, tuberculosis, hepatitis B or C or human immunodeficiency virus infection

The candidate has up to 3 hours to review the medical records and/or coronial instruction and perform the dissection. It is recommended that for the actual dissection of the cadaver and organs, 2.5 hours maximum is taken. If the patient had received named medication prior to death, a recent copy of the British National Formulary will be available for consultation in the mortuary. The examiners will take account of the complexity of each case in judging the timeliness and efficiency of the practical performance of the autopsy.

The candidate should conduct a complete external examination and perform the evisceration him/herself, including removal of the brain. The type of neck incision is not prescribed and depends on the case. The scalp and skull will be opened by the attending anatomical pathology technologist (APT), but the examination of the meninges and the removal of the brain will be done by the candidate. Examiners may observe the candidate during parts of the autopsy examination. Candidates may be required to undertake special procedures, such as dissection of the vertebral arteries, removal of the spinal cord and/or sampling of peripheral nerve etc, as dictated by the clinical history and any limits imposed by a legal authority or consent. The candidate is not expected to reconstruct the cadaver after the examination.

The candidate will be required to demonstrate the autopsy findings to the examiners, discuss the clinical pathophysiology, and present his/her formulation of the cause of death, using the standard ONS formulation.

It is the responsibility of one of the internal examiners to ensure that the autopsy provides the appropriate cause of death as required by the coroner, or if the case is a consented autopsy, ensuring that the report, including the results of further investigations, is presented to the requesting clinicians.

Any tissue retention must be within the Coroners Regulations or consent, and in line with the Human Tissue Authority codes of practice.

The candidate should write up the autopsy by hand. The use of a personal computer is not permitted.

The degree of detail should not be excessive but should include:

• The clinical history summary (e.g. in bullet points)
• The clinical question(s) posed by the death
• The gross findings
• What further investigations (histology, toxicology, microbiology etc.) could contribute to the post-mortem assessment, and why
• A clinicopathological summary
• An ONS-pattern formulation of the cause of death

If no cause of death is evident from the careful gross examination, the write-up will be slanted to the diagnostic possibilities, the means for investigating them further, and the appropriate communications with the parties interested in the autopsy and its results. The examiners will have the opportunity to summate their appraisal of this report, especially in the weighting of clinicopathological issues and the assignation of cause of death, with the oral presentation of the case. This reflects the reality of autopsy practice in which the immediate communication of findings and the later preparation of a definitive report in writing may result in some modification of emphasis.

Assessment will include the following areas:

• External examination of the body
• Planning an appropriate procedure, including ability to make recommendations for best practice
• Technical competence of dissection
• Examination of all major organ systems and major vasculature
• Examination of the nervous system, including sampling in fresh state when required
• Clarity of presentation of findings
• Recognition of pathological features of old age (if appropriate) and appreciation of their contribution (or not) to death
• Recognition and presentation of the clinical issues raised by the death
• Quality of clinicopathological correlation
• Comprehension of relevant pathophysiological and pathogenic processes
• Clarity and structure of the ONS formulation of cause of death

In the write up:

• Clarity of summary of the clinical history and relevant investigations
• Clarity of the written pathological descriptions
• Clarity of the clinicopathological summary

This comprises a brain cut session lasting up to 60 minutes, in which the candidate will be provided with clinical case notes or a case summary and a fixed brain (plus spinal cord if relevant). Candidates will be expected to examine the brain, cut it and present macroscopic findings to the examiners. Candidates may be asked to demonstrate where to take appropriate blocks for histology, giving reasons and specifying subsequent staining. Candidates will be expected to write up the macroscopic findings and include a clinicopathological summary, diagnosis or differential diagnosis, and details of further investigations proposed as appropriate to the case. The candidate will also be asked to comment on the pathological appearances of nervous system tissues in up to 4 additional cases, which have been previously dissected.

Assessment will include the following areas:

• Recognition and presentation of the clinical issues raised by the case
• Proficiency in brain dissection and presentation
• Recognition of the pathological and the normal features in the brain
• Interpretation of the clinical and gross features, and incorporation of the results of any further investigations
• Quality of clinicopathological correlation
• Comprehension of relevant pathophysiological and pathogenic processes
• Sampling strategy for histology, including specification of appropriate investigations.

In the write up:

• Clarity of the written pathological descriptions
• Clarity of the clinicopathological summary

There will be a viva voce examination of the candidate lasting approximately 30 minutes, with focus on knowledge in the following areas:

• Review of the post-mortem case and laboratory section material if appropriate.
• The core principles and regulations that relate to medico-legal practice. These encompass the England & Wales Coroners Regulations and Coroners and Justice Act (and Scotland’s Procurator Fiscal Service legislation if appropriate) with emphasis on the sections relevant to the autopsy, inquests and the taking of tissue.
• Ongoing reforms of the coroners and death certification systems.
• Consent issues for hospital post-mortem examinations.
• The Human Tissue Act and its implications for post-mortem pathology.
• Health and safety aspects of post-mortem practice.
• Special techniques in post-mortem practice.
• Basic medical pathophysiological knowledge, with an emphasis on that pertaining to the pathological investigation of neurological disease.
• Audit and clinical governance

1. The mortuary anatomical pathology technologists (APTs) may assist the candidates by holding parts of the body during the evisceration, and performing the sawing of the skull, but should not perform the evisceration or brain removal.

2. When coronial cases are used for the examination, dissection of the body beyond that required to perform a standard post-mortem examination and establish the cause of death is not permitted. Unless the trainee is already on the coroner’s approved list of pathologists, the body must be identified and examined externally by a supervising consultant pathologist who is on the coroner’s approved list. The supervising consultant will be available throughout the autopsy if required, and will be responsible for interpreting the findings issuing a written report for the coroner.

3. As far as possible, autopsies will be selected from those cases thought unlikely to require an inquest. Cases in relation to which there is objection from the qualifying relatives, a possibility of a serious criminal offence or concern as to the conduct of hospital staff will not be used.

4. Not all candidates will have been trained in England & Wales, where the coronial system operates in the standard manner. In Scotland, the Procurator Fiscal’s role has some differences, and in Northern Ireland, the coronial system also has some differences from the England & Wales version. However, since knowledge of medico-legal autopsy practice is essential and is being assessed in this examination, the guidance is that candidates must be familiar with the common core principles of the legislation and regulations. For most candidates, this will be the England & Wales coronial system.

5. Candidates are expected to be familiar with current the RCPath ‘Guidelines for Autopsy Practice’ and the scenarios for best autopsy practice, available on the College website.

The standard of the examination should test the competence of a pathologist entering their final year of training prior to seeking an appointment as a consultant in neuropathology and should cover the objectives set out in the core training programme.  Candidates will be expected to display that they have potential to practise as an independent consultant in all of the fields addressed by the examination.

The microscopic examination comprises 3 sections, normally conducted over one day:

• Surgical pathology
• Intraoperative diagnosis (smears and frozen sections)
• Complex neuropathological cases

20 cases with accompanying brief clinical details will be provided. Candidates will be expected to write a pathological description, diagnosis and clinical comment, in the form of a report to the physician or surgeon.  For most of the surgical cases only haematoxylin and eosin stained sections will be provided but for a limited number immunohistochemistry may be made available.  Candidates are expected to indicate in their reports if additional stains or investigations are relevant or necessary.

The content of the examination may include tumours, non-neoplastic cases, a CSF preparation and cases from areas of general pathology relevant to the routine practice of neuropathology (for example, skin, head and neck, eye pathology, or axial bone lesions).

A total of six intraoperative cases will be provided for diagnosis, the majority to be smear preparations (stained with both haematoxylin and eosin, and toluidine blue), but some frozen sections to be included.  In this section of the examination emphasis will be given to the delivery of correct and confident advice to aid neurosurgical management. 

This part of the examination will comprise autopsy and muscle/nerve cases, each of which requires assessment and examination of multiple sections.  The sections may be supplemented by additional information such as macroscopic photographs, electron micrographs, clinical data, imaging findings and additional laboratory information (e.g. cytogenetic information or serological data).

This part of the examination will normally include the following:

Two long neuropathological post-mortem cases, with special stains and sometimes macroscopic images.

One or more muscle and nerve cases with histochemical and/or immunohistochemical stains, semithin sections, teased preparations and electron microscopy, if appropriate. Only one muscle or nerve case may be used if the case is particularly complex; more if the cases are relatively straightforward.

In line with the recommendations of the College, a closed marking system is used to assess candidates.  Each section has a theoretical maximum mark which makes a variable contribution to the overall total.

There are 100 marks for the whole macroscopic examination and candidates must achieve 50% to pass this section.  Marking is weighted as follows:

1. Autopsy                               40

2. Brain dissection                  40

3. Viva voce                             20

Isolated failure in only one part of the macroscopic component is potentially retrievable, if the candidate achieves sufficient marks in the other sections. 

There are 150 marks for the whole microscopic examination and candidates must achieve 50% to pass this section. Marking is weighted as follows:

1. Surgical pathology                                      100

2. Intraoperative diagnosis                              30

3. Complex neuropathological cases             20                   

Candidates must pass both the surgical pathology and intraoperative diagnosis sections in order to obtain an overall pass of the microscopic section.   Isolated failure in the complex neuropathological cases is potentially retrievable, if the candidate achieves sufficient marks in the other sections