Quarter of coroner post-mortems 'unsatisfactory'

A quarter of post-mortem examinations performed on the request of a coroner are poor or unacceptable, according to a report out today.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which carried out the study, found that 26% were unacceptable, 52% were satisfactory and just 23% were good or excellent.

It also found that the cause of death registered by pathologists was "questionable" in about a fifth of all cases.

The NCEPOD operates under the umbrella of the National Patient Safety Agency (NPSA), but is a confidential, independent enquiry.

In one third of mortuaries, the pathologist did not always inspect the exterior of the body before it was opened up and the organs removed, the report said.

It also found evidence that elderly patients were not examined as closely as younger patients and that some autopsies were speeded up.

The report, The Coroner's Autopsy: Do We Deserve Better?, which followed a proposal from the Royal College of Pathologists said: "If one quarter of all surgical procedures undertaken on the living were deemed, by peers, to be poorly or unacceptably done, there would be a public outcry.

"The fact that there is no outcry is a manifestation of the fact that families are unaware of the variable quality of the autopsy procedure.

"Indeed it is unlikely that the public would be aware of what constituted an autopsy of good quality."

The NCEPOD said several pathologists had said the £87.70 fee for a standard autopsy without further investigations undervalued post-mortem examinations and put time pressure on pathologists.

The report referred to autopsies ordered by coroners for those who die outside a hospital setting, including in some care homes.

In 2005, 22% (114,600) of the 513,000 people who died in England and Wales, were examined after death through a coronial autopsy.

The NCEPOD reviewed data collected from seven days in May 2005 for England, Wales, Northern Ireland, Guernsey, Jersey and the Isle of Man.

Suspected murder cases were excluded but in all, 1,691 cases were reviewed, made up of 979 men (58%) and 712 (42%) women, with ages from three days to 101 years.

The report found that:

* One in four autopsy reports was poor or unacceptable.

* In one third of mortuaries, the pathologist did not necessarily inspect the body before the it was opened up.

* In one in seven cases the brain was not examined.

* In almost one in five cases, the cause of death stated appeared questionable.

* The very elderly may not have been examined as carefully as younger subjects.

* There was poor recording of the presence or absence of external injuries.

* There was poor communication between coroners and pathologists, with significant gaps in the information given to pathologists by coroners.

It was also discovered that there was a trend to cut the time it took to carry out some post-mortem examinations, with reasons given including cost and the lack of need of such an examination if an acceptable, medical cause of death was easy to register, even if it is not necessarily accurate.

The report noted issues over taking tissue samples for further testing, with some coroner's offices unwilling to increase their workload by asking families for permission to retain samples.