Autopsies—why families count too
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c902 (Published 24 February 2010) Cite this as: BMJ 2010;340:c902
All rapid responses
I would like to express my sympathy to the author of ‘Autopsies – why
families count too’, and my agreement with the statement “I believe it
could have been handled so much better”. The scenario represents a
complete communication breakdown, firstly at the Accident and Emergency
department, and secondly by the Coroner’s office. I have little experience
of the former, but have much experience of the latter, and believe that
the Coroner’s jurisdiction in which I work in has an exemplary model of
dealing with bereaved relatives.
In Newcastle upon Tyne, all bereaved relatives are given a half hour
appointment with a Coroner’s officer the day before the post mortem will
take place. This is to discuss tissue and organ retention; in particular
the fate of any retained tissues once the Coroner has completed his/her
investigation, in line with the Human Tissue Act 2004. Moreover, the
appointment is an opportunity for the relatives to raise any concerns
about the care of their loved one and ask any questions they may have.
Following the post mortem examination, the relatives are contacted by
telephone to explain the results and what happens next. Once the autopsy
report is completed, the relatives can request a copy. Clearly, this level
of interaction between the Coroner’s office and the relatives is not
uniform around the country, a failing that will hopefully be redressed by
the Coroners and Justice Act 2009.
I agree with Dr Finall that the inclusion of the statement “perhaps
pathologists by virtue of their profession are not suited to confront
these issues with the living” is an untrue stereotype, of which further
perpetuation blackens the image of the profession. I myself take pride in
communicating with relatives at inquests and feel it is one of the most
satisfying parts of my job. To be able to give closure and provide answers
to grieving relatives is an honour and a privilege.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
Sadly difficulties in communication with Coroners is not exclusive to just
patients and their families (BMJ 2010;340:c902). As paediatricians,
regularly confronted with grieving parents when their infants arrive in
hospital emergency departments as a result of sudden death, we know that
the majority of these result from natural causes – and for the parents an
explanation is of overriding importance. We do not contest that a
Coroner’s autopsy is vital, however it is our experience that Coroners
frequently do not inform us of the results of postmortems, and our
attempts to gain this information is often frustrated.
We also have concerns about Coroners Officers (police officers)
relaying the results of a postmortem to a bereaved family where the cause
of death has been determined as being due to a complex medical condition –
they may be unable and ill equipped to answer the families immediate
questions.
In spite of national guidelines to improve the investigation of
childhood deaths (Kennedy Report, Sudden Infant death 2005), the Coronial
System certainly in some areas appears to work against the interest of
families at a time when they are most vulnerable.
Yours Sincerely
Peter Rudd,
Fiona Finlay
Consultant Paediatricians, Royal United Hospital and BANES PCT, Bath
Competing interests:
None declared
Competing interests: No competing interests
This article describes a disastrous communication breakdown. As so
often is the case, it occurred at a ‘handover’; at a point of transfer
between two systems. Death with referral to the coroner means transfer
from healthcare (and the Department of Health) to law (and the Ministry of
Justice). The result is a huge shift of emphasis.
With this transfer, secrecy descends to protect the purity of any
evidence that may subsequently be presented in court. Doctors are not
allowed to comment; pathologists are instructed that they must not
disclose their findings without the consent of the coroner. Contrary to
the impression given in the article, it’s not optional. The NHS may want
to help the relatives, but that is not the primary purpose of the Ministry
of Justice.
Dr Finall, in his response, rightly objects to the article for
stereotyping pathologists as ‘not suited to confront these issues with the
living’. Pathologists who undertake autopsies are taught to communicate
their findings to members of the public at a coroner’s inquest. But most
cases, like the one described, do not come to inquest. A few pathologists
do try to explain things to the relatives once the Coroner has lifted the
legal requirement for secrecy. But they must do so without support from
the system, without remuneration, in their own time; and a considerable
amount of time can be taken by such difficult interviews.
It is my personal hope that the new Coroners and Justice Act 2009
will improve these deficiencies.
The anonymous author seems to have had particular difficulty
contacting the coroner and in getting information even after a natural
cause of death had been identified. Hopefully the new Chief Coroner,
introduced by the 2009 Act, will be able to insist on improved
communication from the coroner’s side of the health / law divide.
The mandatory requirement for referral to the Coroner of any death
where the deceased has not seen a doctor for 14 days will stay, which I
regard as regrettable, but coroners will be able to refer deaths of
obviously natural cause back to the new Medical Examiner system for
certification.
Medical Examiners will also be placed to check whether or not cases
need referral to the coroner in the first place. Pilots of the system
have already demonstrated that referrals, and unconsented post-mortem
examinations, will be reduced.
Medical examiners will also (I hope!) improve communication with the
bereaved. The new system was initially developed ‘to catch the next
Harold Shipman’; but as a result Medical Examiners will be obliged to
offer an interview with every bereaved family. Unless the Coroner is
investigating, of course. There is as yet no expectation that Medical
Examiners will discuss deaths certified by the Coroner. Should that be
changed, or is that the Coroner’s job?
The meeting between Medical Examiner and the bereaved should be a two
-way communication. The family should get a comprehensive, independent
explanation of why their relative died. But the Medical Examiner should
also get the family’s perception of defects in the system, of things that
went wrong, and will have a duty to inform NHS Clinical Governance
systems.
If the Medical Examiner system had been in place in Mid
Staffordshire, recent events there might have been very different.
Competing interests:
The author is President of the Royal College of Pathologists, which will be Lead College for Medical Examiners of the Cause of Death. He Chaired the intercollegiate working group that defined the curriculum for training Medical Examiners and has been involved in developing and piloting the new system.
Competing interests: No competing interests
The article should open every doctors eyes to the heartbreak that
relatives or loved ones suffer when a patient dies. During busy takes or
acute settings we often overlook the "soft touches" that are demanded by
someone passing away.
The piece shows how important basic communication and explanation can
be in not only helping relatives come to terms with a death but also in
preventing complaints.
I feel is also reflects yet another aspect of defensive medicine we
now practice in referring any death with even the slightest doubt to the
coroner. However, this does not prevent us from keeping family members
involved.
At our hospital there is a bereavement officer who is a lay person.
She contacts all families of deceased patients to guide them through the
certification process and in the case of referrals, advises and updates
the family on coroners decisions and investigations. The family also have
an opportunity to make an appointment to discuss any concerns or
questions.
The new Cremation form also asks for this to be done but I think as a
profession and a society, we still consider death very much a taboo topic
that is not discussed and pushed out of sight, but not out of mind as this
piece passionately shows.
Competing interests:
None declared
Competing interests: No competing interests
I empathise with the anonymous author about the perceived lack of
sensitivity
of the current Coroner system [1] and hope that things will improve
following
the introduction of a "Charter for bereaved people who come into contact
with a
reformed coroner system" which is expected in April 2012.[2]
I recognise that anger is a natural part of the grieving process but
however
useful it may have been for the author to express his/her frustration with
this
system through this article, I feel it is regrettable that use of
professional
stereotypes was not edited out, particularly as its inclusion seemed to
add
nothing to the piece. Describing pathologists as “not being suited to
confront
issues with the living by virtue of our profession” is a view that is
unjustifiable
and one I would have hoped the BMJ would not wish to be seen perpetuating.
1. Anonymous. Autopsies- why families count too. BMJ 2010; 340:c902
2. www.justice.gov.uk/publications/draft-charter-bereaved.htm.
Accessed
27th
February 2010
Competing interests:
Histopathologist
Competing interests: No competing interests
As a histopathologist who carries out post mortem examinations for
the Coroner I would like to start by offering apologies for all the upset
and unhappiness that has been caused. Pathologists are human beings too,
some of us meet bereaved families and see the effects we can have on them.
In addition to apologies, explanations. The law is what it is. There is
clear guidance on which deaths must be reported to the Coroner, and if the
Coroner decides to investigate the matter is entirely out of the hands of
the hospital staff and pathologists. In particular, pathologists have no
say whatsoever in which cases come to autopsy, neither have hospital staff
the discretion to break the law. The Coroner also must obey the law. Now
the law is different in Scotland, and far fewer post mortem examinations
are carried out, as the Procurator Fiscal needs to exclude criminality and
neglect, and often this can be done without an autopsy. It is to be hoped
that forthcoming changes in the law in England will reduce the number of
autopsies to those that are really necessary.
It is a paradox that in England too many autopsies can be seen to be of no
great benefit and the evidence suggests that many of those that are
necessary are not done to a high enough standard. Perhaps a fall in
numbers would allow this to happen. I wish to finish by repeating the
apology. Dear Writer I don't know who you are, but you have truly shaken me
this morning.
Competing interests:
I am a histopathologist who carries out post mortem examinations for HM Coroner.
Competing interests: No competing interests
The importance of coroners officers and family communication
As a pathologist experienced in sudden death in the community with a
national referral practice in this area I sympathise deeply with the
author of the article. It highlights dramatically the lack of
communication which can occur between families and the coroner with
misunderstandings which adds to the emotional trauma and anxiety at a very
stressful time. Most lay people are blissfully and totally unaware of the
wide powers of the coroner when a sudden death occurs. After the medical
team dealing with the case informs the coroner, usually through the
coroners officer ( a retired police officer or lay person ), then once the
case is accepted, the body of the deceased becomes the property of the
coroner until released by him to the family after completion of enquiries/
autopsy. No wonder families feel isolated and powerless in such
situations. The central role of the coroner's officer is crucial at this
time to act as a conduit of communication between the family and the
coroner. Their role is crucial and undervalued. In my experience a
skilled, experienced and well trained coroner's officer will explain all
the issues to the family. They will also have a close relationship with
the pathologist who carries out the autopsy and communicate to him/her the
complexities of the case from the family point of view. Thus the
pathologist will be sensitive to any anxieties and may also get valuable
additional information which may help with the cause of death. This takes
time and considerable emotional imput from these often undervalued
individuals within the coroner's office. Many coroners have such skilled
personnel but not all. I personally have built up a relationship with many
coroner's officers throughtout the UK and Ireland and would not be able to
carry out my work without them.It is in the training and experience of
these individuals that such situations as described by the author can be
avoided. Recognised training schemes and guidelines in such sudden dearths
for coroner officers should be applied nationwide.
Competing interests:
None declared
Competing interests: No competing interests