Post mortem examination: barriers to excellence?

2. Post mortem examination: barriers to excellence? Emyr Wyn Benbow Royal College of Pathologists

3. The barriers? • Department of Health • Ministry of Justice • The Coroners' Society of England and Wales • Primary Care Trusts • Foundation Trusts • Royal College of Pathologists • Pathologists • Awdurdod Meinwe Ddynol

4. The barriers? • a sign at the junction of Clase Road and Pant-y-Blawd Road in Swansea

5. The barriers? • and a sign put up by Vale of Glamorgan Council

6. Awdurdod Meinwe Ddynol • “The Horticultural Trades Association is run by the garden industry for the garden industry. We're dedicated to growing business for garden centres…” • www.the-hta.org.uk • www.hta.gov.uk • www.hta.org

7. The barriers? • Department of Health • Ministry of Justice • The Coroners' Society of England and Wales • Primary Care Trusts • Foundation Trusts • Royal College of Pathologists • Pathologists • Human Tissue Authority

8. Do we need excellence? • Quality of autopsy reports: NCEPOD

9. Do we need excellence? • Quality of autopsy reports: NCEPOD 2005

10. Do we need excellence? • Quality of autopsy reports: NCEPOD 2005

11. Quality of autopsy reports: NCEPOD 2005

12. Quality of autopsy reports: NCEPOD 2005 Quality of external descriptions

13. Quality of autopsy reports: NCEPOD 2005 Quality of organ evaluations

14. Quality of autopsy reports: NCEPOD 2005 Quality of report with respect to histopathology

15. Quality of autopsy reports: NCEPOD 2005 The cause of death Satisfactory = "appropriate account for the clinical course and autopsy findings as presented in the report and in the supporting documentation". 18% (310/1,691) of cases did not meet this criterion

16. Classification of discrepancy l a discrepant primary diagnosis with adverse impact on survival ll a discrepant primary diagnosis with equivocal impact on survival lll a discrepant secondary diagnosis not related to cause of death, but which should have been treated, or which would have eventually had an impact on prognosis lV a discrepant non-diagnosable secondary disease V nondiscrepant diagnoses Battle RM et al, JAMA 1987; 258: 339-44

17. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA 2003; 289: 2849-56 • systematic literature review, 1966 – April 2002 • 45 papers, 53 studies • median error rate was 23.5% (range, 4.1-49.8%) for major (class I and ll) errors • median error rate was 9.0% (range, 0-20.7%) for class I errors

18. Shojania et al, JAMA 2003; 289: 2849-56

19. Shojania et al, JAMA 2003; 289: 2849-56

20. The barriers? • Department of Health • Ministry of Justice • The Coroners' Society of England and Wales • Primary Care Trusts • Foundation Trusts • Royal College of Pathologists • Human Tissue Authority

21. Department of Health • Death certification subgroup • improve the quality and accuracy of death certification • introduce a single system of effective medical scrutiny applicable to all deaths not requiring coronial autopsy or inquest • provide improved information on cause of death to strengthen local clinical governance and public health surveillance

22. Ministry of Justice Coroners and Justice Bill • The main purpose of the Bill is: • To deliver a more effective, transparent and responsive justice and coroner service for victims, witnesses, bereaved families and the wider public.

23. Ministry of Justice • The main elements of the Bill are: • Creation of a new national coroner service, led by a new Chief Coroner, moving towards whole time coroners working within flexible jurisdictions and to national minimum standards, with powers to commission non-invasive post-mortems where appropriate, and complying with a charter of services for bereaved families

24. Ministry of Justice • The main elements of the Bill are: • Creation of a new system of secondary certification of deaths that are not referred to the coroner, covering both burials and cremations

25. The benefits Summary of savings/benefits • Greater rights for bereaved people through introduction of appeals process • Improvements to case handling • Greater medical input to investigations. • Fewer unnecessary post-mortems. • Greater consistency across coroner jurisdictions from introduction of national standards and leadership. • Co-operative working with coroners to develop training, charter and other initiatives for bereaved people supported by strong positive central lead • More effective handling of cross-districts major emergencies • Greater accountability through inspection arrangements

26. The Coroners' Society Total deaths reported to coroners, 2008 234357 Deaths reported where a post-mortem took place 108360 Deaths reported without a post-mortem 126424 Deaths reported where an inquest was opened 30999 Inquest was held without a post-mortem 2481

27. The Coroners' Society  Inquest cases Post-mortem examination held No post-mortem held 2000 24,117 97.0% 740 3.0% 2001 24,617 95.4% 1,176 4.6% 2002 25,363 96.0% 1,067 4.0% 2003 25,754 95.0% 1,359 5.0% 2004 26,618 94.1% 1,656 5.9% 200527,537 94.1% 1,734 5.9% 2006 27,305 93.1% 2,022 6.9% 2007 28,510 92.4% 2,331 7.6% 2008 28,518 92.0% 2,481 8.0%

28. The Coroners' Society

29. The Coroners' Society Survey of 406 histopathologists: • CONCLUSION: The circumstances under which coronial autopsies are conducted in many parts of the UK make it difficult or impossible to comply with current RCPath guidance… resolution of this dilemma requires clarification of exactly what a coronial autopsy is trying to achieve. MJP Biggs, Brown LJR, Furness PN. J Clin Pathol 2009; 62: 515-9

30. Primary Care Trusts • “commission” hospital services, including laboratory medicine • will employ Medical Examiners

31. Foundation Trusts • “own” most mortuary services in England and Wales • employ the majority of histopathologists who are autopsy-active • take wildly disparate approaches to the incorporation of Coroner’s autopsies into job plans

32. Royal College of Pathologists • sets standards for autopsies • FRCPath examination • recent modularisation • progressing to an OSPE-style examination • guidelines on autopsy practice • 2002 and 2005 • best practice scenarios • coronial autopsies and current practice: accuracy of cause of death and tissue sampling • November 2007

33. Royal College of Pathologists • best practice scenarios • sudden death with likely cardiac pathology • autopsy for sickle cell disease and sickle trait • autopsy for suspected acute anaphylaxis • sudden unexpected deaths in infancy (SUDI) etc, etc

34. Royal College of Pathologists • accuracy of cause of death and tissue sampling • The GMC FTP Panel stated: “Professional bodies such as the police and coroners place reliance on the information provided by pathologists. The families of the deceased were entitled to an accurate diagnosis of the cause of death. It is therefore important that the conclusions stated in such reports can be verified”.

35. Royal College of Pathologists • accuracy of cause of death and tissue • The 2000 version of Guidelines on Autopsy Practice states in paragraph 4.6.4: “Coroners’ autopsies should be reported to the same high standards recommended in the College’s existing guidelines, and now described in these Guidelines.”

36. Pathologists Survey of 406 histopathologists: • Conclusion: The circumstances under which coronial autopsies are conducted in many parts of the UK make it difficult or impossible to comply with current RCPath guidance. Pathologists disagree on whether this situation demands a reduction of RCPath standards, an improvement in autopsy practice in medico-legal cases to current RCPath standards, or the implementation of double standards. MJP Biggs, Brown LJR, Furness PN. J Clin Pathol 2009; 62: 515-9

37. Pathologists • “I am stopping… massively influenced by my belief that the RCPath recommends things that are 'over the top' in the context of tax payers having to fund what we do” • “Coroner is completely unpredictable and often does not allow best practice” • “autopsies are becoming more and more onerous and I would quite like to stop doing them” MJP Biggs, Brown LJR, Furness PN. J Clin Pathol 2009; 62: 515-9 suppl

38. Pathologists MJP Biggs, LJR Brown, PN Furness; J Clin Pathol 2009; 62: 525-9

39. Pathologists • “… the general standard of coronial postmortems is a disgrace to the profession. The grubbing after money by those uninterested in autopsy pathology is sordid and unprofessional. It needs root and branch reform and a genuine lead from the college, not appeasement of those with vested interests”. MJP Biggs, LJR Brown, PN Furness; J Clin Pathol 2009; 62: 525-9 suppl

40. Pathologists • “… at best this work is fascinating, provides great opportunity for teaching and provides a modest/minimal extra income. At worst it is pretty gross and I think many pathologists would prefer to drop the work if it became too onerous or if the income generated was not worth the effort” MJP Biggs, LJR Brown, PN Furness; J Clin Pathol 2009; 62: 525-9 suppl

41. Human Tissue Authority • “The Human Tissue Act is a disaster. It has taken all academic interest away from autopsy practice. The Human Tissue Authority is an unhelpful organisation that should be abolished.” • “The Human Tissue Act has just succeeded in increasing bureaucracy associated with carrying out ancillary studies at autopsy. We perform too many autopsies for the wrong reasons.” MJP Biggs, LJR Brown, PN Furness; J Clin Pathol 2009; 62: 525-9 suppl

42. Human Tissue Authority • “We are encouraged to provide a sloppy and inadequate service because of the constraints applied by the Human Tissue act and coroners rules, the lack of time due to the service being outside the NHS and the inadequate remuneration” • “an invaluable service but not enough time and resources and grave limitations due to the Human Tissue Act.” MJP Biggs, LJR Brown, PN Furness; J Clin Pathol 2009; 62: 525-9 suppl

43. Human Tissue Authority • so is Human Tissue Authority a barrier? • a real barrier? • or a virtual barrier?

44. The End - but this is just the end of the beginning!

46. Working together; building confidencePost mortem sector conference Wednesday 21 October 2009