The following text represents the complete free-text responses of pathologists to the online questionnaire described in the paper “Online survey of current autopsy practice” by Biggs, Brown & Furness, published in the Journal of Clinical Pathology 2009 (add full reference when available)

It is reproduced here because of lack of space in the printed journal.

The comments are irreversibly anonymised, unedited (apart from obvious typographic errors) and unabridged.  They are unselected and are presented in the order of submission to the system.

I am stopping on 1.1.08.
Partly due to going on to new contract.
Also 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. So I feel that many pathologists are in a very difficult position.

RCPath and NCEPOD expectations for quality of routine coronial autopsy are very out of touch with the working reality.

Coroners poorly remunerated ( eg ridiculously close to a cremation fee for much more work). Coroner is completely unpredictable and often does not allow best practice.

It is done to a high standard and very promptly.
The quality of work by the coroner's officers is very poor esp. poor history, not asking for hospital notes to be sent, slow in getting cases organised for PM.

Autopsies are becoming more and more onerous and I would quite like to stop doing them.

MANY CORONERS PMS CARRIED OUT ON HOSPITAL INPATIENTS BUT HAVE TO DO THEM TOO QUICKLY BECAUSE OF HAVING TO TIME SHIFT. SHOULD BE SOME ALLOWANCE FOR THEM TO BE PART OF DCCS.

I DO NOT THINK IT IS WISE SAFE OR PRACTICAL TO HAVE A SUBSTANTIALLY DIMINSHISHED STANDARD OF CONDUCT FOR CORONER’S PMs - IF THE BODY IS DISSECTED BEFORE INSPECTION BY THE PATHOLOGIST, ACCIDENTS ARE BOUND TO HAPPEN OCCASIONALLY, I HAVE KNOWN THIS HAPPEN HERE IN FORMER YEARS DESPITE HIGH QUALITY MTOs AND A GENERALLY CAREFUL WORK PATTERN BY BUT PATHOLOGISTS AND TECHNICIANS. IN MY HOSPITAL THE MORTUARY IS 'OFF SITE' AND INCONVENIENT TO VISIT WITHIN A CROWDED NHS DAY BUT I BELIEVE THAT A MINIMUM SAFE STANDARD MUST BE MAINTAINED. THE COLLEGE GUIDLINES COULD ADMIT A LITTLE MORE PROFESSIONAL JUDGEMENT, AFTER ALL WE ARE REGULATED PROFESSIONALS, NOT 'NURSE PRACTITIONERS' NEEDING AN EXHAUSTIVE 'SOP'

Clearer explicit guidance on the purpose and aim of Coroner's post mortems is required.

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.

I feel I do my best with the resources available. There are obviously time and cost pressures in operation, and undoubtedly I take less histology than in previous years, as I only take it now when there is an absolute indication, rather than a more vague need.
The remit for HMC PM's is basically to find the cause of death.

My responses applied to adult coroners cases (since could only give one response). Obviously my practice is very different when dealing with baby coroners cases or hospital PMs for adult or baby.

1. Having trainee pathologists is very time consuming. They do not contribute to workload at all as they are very slow and require close supervision
2.I think my answer to the question about coronial practice is misleading. The number of PM's is about right but the coroner accepts some cod's he shouldn’t and doesn’t accept some he should
3.** trust has accepted that part of our pm workload comes under SPA's for teaching and audit ( 50% agreed). This is fair as we have a high proportion of hospital deaths and a low proportion of community deaths, but if you have trainees there is always a teaching component. I think you should ask about this

Would like to give it up asap

coroners autopsy fee insufficient for the time, responsibility and work
difficulty in obtaining the higher fee from coroners for cases I feel are appropriate for the higher fee

Generally I think there are too many inappropriate cases referred to the coroner. We have no control over which cases are referred or which cases go on to have an autopsy. There ought to be a system whereby cases can be turned down. Pathologists need to regain control of what is demanded and what can be done in individual cases without reference to the coroner or coroner's officers.

If given the choice, under the present system I would happily give up doing autopsies for the coroner despite the financial penalty.

I do enjoy the work however i do not feel the training completely covers all the scenarios one would come across in a DGH environment. I have learnt an awful lot over the past 3 years working in a DGH and carrying out over 500 cases. have used the college scenarios extensively and have referred cases back to my trainers. it would be helpful to have the opportunity to have some more in-depth training via the college e.g. post op deaths, suicides, road traffic collisions, head injuries, deaths in drug addicts, the unremarkable autopsy, assessment of injuries, etc.
Have had difficulty with some Coroner's officers but have managed to discuss cases with the Coroner and between us we can often solve any problems or issues.
Usually I find it is lack of information before the autopsy, or being given incomplete information, which has been the problem; especially when something major comes to light later-on.

I think it should be stressed that a pm is composed of macro and micro. The components should not be dissociated. So if the coroners request or the next of kin agrees to a pm it should by default be complete.

Majority of coroners post mortems should not be necessary.

Far too much variability in the expectations/requirements of different coroners. Too much delegation of decision making to poorly trained/unqualified coroners officers.

Could we see the result of the survey indicating where ones answers lie amongst the cohort of respondents?

I am considering dropping autopsy work in the near future due to increasing pressure of NHS biopsy work, coupled with changing to 2003 NHS consultant contract. I also perceive an increasing medicolegal risk with potential multiple jeopardy.

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. Either there needs to be a change in attitude towards death certification that allows deaths to be designated as natural causes without the need for a detailed cause of death or there has to be appropriate investment in autopsy services to allow for more to be performed so allowing more precise death certification. I think we would be making better use of our time if we were performing post mortem examinations on patients who have died following expensive treatments (surgery, chemotherapy, radiotherapy) rather than on old people who have died at home without seeing a GP for several days.

I am happy to carry out consented autopsies as the law/consent issues are clear. I am highly ambivalent about continuing to undertake Coroners' autopsies; in fact I stopped for several years and only recently restarted. There is a discrepancy between what one ought to do (and RCPath guidelines) and what one is legally able to do. The resources do not permit one to carry out coronial autopsies to the standards expected by the RCPath. The remuneration for this somewhat unpleasant and medicolegally risky work is poor.

Not paid well enough for all the hassle currently. Doing it just to support Colleagues!!

Although he number of coroners PMs may be about right, the cases which are autopsied are often inappropriate and unnecessary, while other cases which should be autopsied are signed up. This sometimes seems to have more to do with wishes of relatives then answering important questions. For example, we frequently do PMs on very elderly patients with extensive known diseases simply because the GP hasn’t seen them recently, while other in-hospital deaths with lots of questions outstanding will get signed up.

I think that autopsies should be part of my contracted role and allocated appropriate time. There is a tension between the NHS role and the coroner’s role which is fostered by the current contract and the financial rewards of the coroners system. There are considerable tensions locally between the coroner and pathologists in the interpretation of HTA rules and coroners regulations and particularly in relation to providing information to families. This leads to an unsatisfactory situation regarding histology.
I am greatly concerned that trainees are seeing a very limited range of autopsies and are not able to routinely examine autopsy histology.

Length of time taken is irrelevant unless fee is time-based - the fee is/should be a professional fee and needs to be substantially increased in any event - if you pay peanuts etc...

Publishing two standards is inappropriate, but so is publishing one standard as if one size fits all. It is a myth that coroner's autopsies are 'forensic' autopsies and should be done to the same standards as those where there is an active suspicion of foul play. Standard coroner's autopsies are not and cannot be for excluding foul play (this is a police matter), they are for establishing a reasonably sound cause of death. The published guidance needs to be changed to reflect an appropriate 'horses for courses' approach to autopsies. This is not about 'diluting standards' (the one size fits all approach is obsessional, inappropriate and also ineffectual because not - and never will be - followed by most experienced pathologists), it's about having a sensible approach to the autopsy and allowing resources to be properly directed to cases where they're most needed.

It should be a recognised subspecialist interest.

The inconsistencies in coronial requirements make it very difficult to stick to standardised guidelines

Autopsy practice contributes immensely to education in particular nurse education. A nurse's training must be questioned when they comment on simple points e.g. relative sizes of the organs and their relationships.
Doctor colleagues are misinformed about the value of the autopsy as demonstrated in their mortality audit meetings which are sanitised and free of pathological input although we go to the meeting!!

The scope and expectations of the Coroners post mortem should be defined legally ( ? "limited to establish on the balance of probabilities the cause of death ") and made clear what are the current limitations set by resources and the HTA.

The current death certification and coronial practice is generating far too many coronial autopsies whose value is limited by the absence of histology (see above). Autopsy histology is a valuable form of Quality Control.
Personally I have difficulties in justifying the payments made to NHS pathologists for carrying out coronial autopsies as there is inevitably some impact on NHS duties. I would prefer it if there were fewer better selected cases if payments are to continue. We are however fortunate in being allowed to use coronial autopsies for training juniors

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.

less numbers in recent times...fallen by more than 50%

Lots of trainees complain about the discussion that takes place after the post mortem examination and the fact that most Consultants do not take time to conduct an exam style discussion for the cause of death and how to arrive at this conclusion. fellow Consultant pathologists trained in the EU are sometimes use the cause of death section to list reasons for death rather than use the Ia "due to" Ib etc.

The coroners are requesting smaller numbers of more complicated autopsies. This is causing a reduction in money earned per hour of work. This is making coroners work less attractive. There is a younger generation of pathologists who will not bother with coroners work unless there is an appropriate increase in fee per case or more widespread offers of special PM rates by the Coroners.

Some of these questions demand a yes/no answer inappropriately. The mortuary technicians sometimes open and eviscerate when the history is highly suggestive of a natural death but they do not do so for example in post-operative deaths.

The Coronial Service in this country does not serve the interests of diagnosis, understanding the pathogenesis of disease, teaching or research. Indeed there are too many Coronial Post Mortem examinations and too few Hospital / Community Medical Post Mortem Examinations.
It is likely that Coronial PMs do not serve the purpose of detecting suspicious deaths.

Guidance MUST take in to account
(1) the reality of the way Coroners behave re. sampling for histology etc, and their reluctance to agree to anything that adds to cost, complexity, or time.
(2) the real constraints of the Human Tissue Act.
One cannot require a standard that is unachievable because of issues beyond the control of the Pathologist (eg. Coroners behaviour), and then criticise the Pathologist (cf. CEPOD report!).
Also, one has to be realistic - the coroner is NOT going to pay for more histology etc. when their budgets are pressed.
I, for one, will be giving up autopsy practice at the earliest opportunity (I only continue with it to ensure a local service is sustainable, so that relatives are not inconvenienced and we can maintain reasonable standards of practice and sharing of information with clinicians, which would not happen if they were shipped off to the "factory line" else where). The "fee" is derisory for the effort and potential complexity. We have a coroner's officer who filters cases effectively, so we have a higher proportion of complex cases.

I think that autopsy practice in England risks becoming a marginalised and Cinderella subspecialty. There are many reasons for this but I am really concerned about what is going on nationally

1. The move to hold a no autopsy MRCPath examination will mean that in the future many pathologists will not be trained in autopsy techniques and skills meaning that the load of autopsy work will fall on a shrinking number of more senior pathologists

2. Autopsy work has become far more problematic in the 10 years that I have been a Consultant. This is partly due to the HTA but mainly constraints imposed by local coroners who will not allow tissue retention event when it is required to establish a medical cause of death. I was recently told by my coroner in a case where an elderly Muslim diabetic lady had died of a subdural hematoma due to a skull fracture after falling down stairs that I could not take cardiac histology to look for amyloid; I assume that she had had an arrhythmia due to amyloid and fallen downstairs and fractured her skull-the reason-because she was Muslim and this would cause relatives concern.

3. It seems that everyone that dies in hospital now has some sort of complaint or issue with the hospital or GP's care and that it is really crucial to spend a large amount of time reading the notes, and being careful how findings are expressed in written reports, and also talking to clinicians. This all takes time and the £90 or so fee does not compensate for the stress and aggravation. Remember that most SPRs and SHOs no have little or no knowledge of patients as they work shifts, often in complex cases no one really knows what has gone on (including the named Consultants looking after patients). The system is broken and getting relevant information in some cases prior to starting PM's is impossible. Everything then becomes a judgement call as to whether the risks of refusing to do or delaying a PM case are outweighed by the time taken dealing with a relatives' complaints when a case is delayed until all the facts of the case and the full medical case record becomes available. Catch 22 as ever for pathologists!!

4. I have real concerns that the recent NCEPOD reports have given a distorted picture of autopsy practice and the language used in the reports by pathologists who drafted these reports was, with hindsight, not properly thought out and overly critical of what pathologists do.

5. The rate of pay for coroners work which I estimate is less than £50 an hour is less than that paid to WTE consultants on the new contract in many cases, it is also not pensionable, and the autopsy work is far more taxing and stressful that reporting biopsies or MDT work

6. Should pathologists be time shifting to do autopsy work??? particularly if they are working at strange hours, exceeding the 48 Hour EC working time directive. Doesn't this have governance, health and safety and quality implications???

In summary we are at a crossroads and autopsy practice may wither unless the DOH and HM government take the whole thing seriously and invest in the service for the future.

Either standard reflects fee or fee increased to match aspirational standard

Trainees must be allowed greater opportunity to carry out more autopsies including more complex cases.
Opt out of autopsy training will add to workload and workforce problems.

As stated I feel that Government has not valued the work, THE RCPath has been high handed in the standards it has tried to lay down - constantly trying to show what a poor standard of service is given, the work is poorly remunerated and the only reason we have continued to provide the service is the training requirement for our 3 SPRs.

I am on the point of chucking it in. It’s too much hassle, and a huge amount of stress, for very little reward. The audit/teaching/research aspects are wonderful in theory, let alone the "social" value ("closure" for the bereaved). But the HTA procedures are threatening and hugely awkward. The trust/new contract makes me feel like I'm cheating, despite the income they make from it too, and the reliance on us doing it for audit and teaching. Most of the cases should be written up anyway, and don’t need PMs, but no one listens to my opinion. Increasing numbers of families are litigious and complaining. It's physically highly unpleasant, and potentially risky. And I have a million other things to do. But I fear for the future pathologists-in-training, as I think it helped hone my clinical and diagnostic skills over the years.

Prescriptive mandatory points are easily computer stock phrase generated and are no indication of the quality of PMs - which I may vary from case to case on its merits but is not measurable objectively

would like at attend a PRACTICAL update course on sudden death

Qu. concerning head is poorly worded. I take it on relevance to case but there are many situations where I automatically examine eg post-op. Examinations are becoming more complex and time consuming; the latter especially when undertaken with SHO. I would like the coroner's consent to include permission for limited histology in all cases, but information would still be fed back. I would like to see cases fee banded so that some cases e.g. maternal deaths, complex post -ops, etc would attach special fee without having to beg the coroner for it!

too poorly paid what do you expect for £93

I appreciate that it is difficult to get simple answers from a questionnaire. However there are questions here where the answer is more complex than one can respond to.
I believe that it is important to take the history, site of death and appearances to determine what you should to use your time to best advantage to provide a good quality service.
Our Trust is restricting the time that it will permit us to do post-mortems [2 hours pre week] so that combined with staffing problems in the mortuary, difficulties in communicating directly with the coroner's officers and the complexities that arise from the Human Tissue Act it is difficult to work efficiently. I do not believe that the current fee of a Coroner's post-mortem is appropriate to time shifting. It is extremely low as a fee either professionally or not. The Trust is also trying to outsource the post-mortem service, yet there are a substantial number of hospital Coroner's cases. Most of the community Corner's cases are not complex, though owing to historical storage issues we transferred most of the simple community deaths to another hospital which have not yet returned now that storage should be resolved. The Trust have been advised and warned by us of the wide ranging issues that will follow if they take this approach. I fear for the post-mortem in this country. I expect my privacy and identification to be protected by yourselves.

We have real problems with extremely low numbers of consented autopsies that make skill maintenance and training difficult.

TOO MUCH POLITICAL CORRECTNESS

I enjoy performing autopsies but my trust is not particularly supportive of me doing them and I am considering stopping them soon.

I feel there has to be a consistency in training and autopsy practice in all regions.
Clinicopathological correlation should be taught to the trainees by the peers in the region.
There should be a protocol laid down for taking microbiology and toxicology samples with agreement about the costing and the importance of these tests with the coroner.
Should autopsy free exams be introduced, the trainee should be trained and examined by the RCPath appointed peers.

The constraints placed on the autopsy practice by the human tissue act, and the inability to perform autopsies to a high standard due to the fact that they are all coronial means that I am seriously considering withdrawing form this aspect of my work.

The coronial system needs review. It needs investigate not only the cause of death, but be extended to look at any disease processes present in the deceased which may be benefit to the wider community as a whole. I think it is great mistake that so much public money is spent on the coroners system, yet it remains very restricted in its remit.
The Human Tissue Act should be amended to ensure histology samples are taken as a routine part of the examination and when taken retained as part of the record, in ALL cases.

I ticked that I perform post mortems but I only do hospital cases now and my answers may not be applicable to the survey. I stopped doing coroner's autopsies a couple of years ago for several reasons - time constraints and resulting stress, the unpleasantness of the task and the medico-legal aspects such the Human Tissue Act and deficient and sometimes misleading coroner's officers' reports. With all the adverse publicity I became more fearful of only hearing a vital bit of history at the inquest and my time-constrained problem orientated PM being rendered apparently incompetent. It would take a lot to make me do them again.

Our practices vary with how busy we are, and how many technicians are present. My preference is to open and eviscerate all cases myself, but when busy, as I do one case, the technician will start the next one in my presence. I do not permit any other than the next case to be opened in case of running out of time. Histology has become a bureaucratic nightmare, and I avoid it unless it is absolutely essential. It can only be done if the coroner consents.
We time shift, we also have a workload management system which lays down how much work must be done, and autopsies do not count towards our work. It would be very difficult for us if a colleague decided not to do coroners autopsies, and we would not be able to take up the extras.

VERY VARIABLE STANDARDS THROUGHOUT UNITED KINGDOM

The combination of job planning and resource constraints is making it difficult to provide a local coroners autopsy service. Recent RCPath guidance has highlighted the difficulties and now most of my colleagues would rather give up doing post mortems altogether. As head of department, this makes rostering for autopsies problematic and creates tensions between local coroner’s officers and pathologists.

Having been a consultant for 22 years I feel that the range of cases that I was asked to do in the past was more professionally satisfying and not done any less well than the routine and restrictive recommendations of today.

Coroners need to be more targeted in the cases they submit for autopsy.

Background information provided to pathologist from coroner is often woefully inadequate

A meeting with the family is very important, in terms of proper communication and the public perception of the autopsy. Pathologists who are not willing to meet families should be excluded from autopsy practice.

Some of the questions demanded answers when none of the above would have applied - rather a narrative.

Especially on the section of technicians opening bodies under "consultant" supervision when the consultant may have reviewed the case details and arranged a time attendance at the mortuary. Also when this is variable practice depending upon the nature of the case.

Should do fewer, but to a higher standard with routine histology.

Autopsy practice should not be considered solely like private work. It should be a part of the NHS Job plan. The remuneration like £93 should be considered as fee not to perform autopsy but to write a medicolegal report for coroner services. The performance of autopsy procedure must be a part of the job plan. So that we could retain pathologists interest in the field.

I think that the current legislation regarding the taking of samples for histology in coroner's PMs greatly limits the usefulness of the post mortem and limits training of juniors like myself even more

Underpaid

There is an element of coercion of those who continue to undertake coroners work:
1. Younger appointees refuse to perform these autopsies (often claiming inexperience, or a conflict between the standards required by the RCPath, and the conditions imposed by coroners).
2. Hospital consent cases are few (partly because of the new extended consent forms that are required, and cases which otherwise would not be coroners cases, nowadays become so because clinicians feel this is an "easier" route to autopsy).
3. Trainees require autopsy experience to satisfy RCPath requirements.
4. And so the older generation of general histopathologists are forced into a position of taking responsibility for corners autopsies to satisfy training and ("quasi-consent") hospital service needs.

We ("general histopathologists") are being put into a position thereby of accepting individual professional liability for the provision of a comprehensive forensic pathology service (cf Dr Bee 2004 GMC case) when we have neither the training, facilities nor funding to do so.

I object to continuing to undertake coroners autopsies because:
1. My training and natural inclination is to undertake autopsies for medical education and curiosity.
2. To have to regularly make macroscopic diagnoses without routine microscopic confirmation as is the case with coroner’s autopsies, is a compromise too far, as far as I am concerned. This offends my personal as well as my professional standards.
2. I am not willing to regard my clinical colleagues with the level of suspicion that is necessary for forensic work.
3. The payment for coroners work is insufficient to compensate for the risks involved considering that the NHS regards this work a "private practice".
4. Furthermore there is a serious conflict of interest in that the coroners ("quasi-consent") hospital autopsies are being performed by colleagues of the patients’ clinicians and employees of the hospital in which malpractice may have occurred.

We are propping up an archaic, cut-price pretence of a forensic pathology system, at considerable personal professional risk, at a time when the coroners system, the GMC, and the RCPath have assumed
irreconcilable positions.
In my opinion our present position is untenable and unacceptable.

If it were not for the requirement to somehow find autopsy cases for trainees, I would resign from the coroners list immediately.
The sooner the RCPath removes the autopsy requirement for general histopathology training the better (and as noted above, in any case this meagre training in autopsy work is irrelevant for many trainees as soon as they are appointed to a consultant post).

Coroner’s autopsy work should be performed properly by properly trained independent forensic pathologists, who should be paid properly.

There are pressures on our practice as some colleagues wish to drop doing them. They only carry on so as not to burden colleagues. The number of PM's done is not sustainable. We all probably know of complex multifactotial hospital deaths which probably should have had a coroner’s PM but didn’t, and elderly patients with an obvious cause of death from the medical history and circumstances of death that are not issued. The balance needs to shift so that we are using the limited resources (consultant time) to the greatest effect.

The Precise purpose and level of detail of the Coroner PM needs to be established and supported accordingly (with both legislation and funding). I am concerned that fewer new consultants are doing coroner PMs.

The general standard of coronial PMs 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.

I take a problem-oriented approach to a coronial autopsy, where the aim of the examination is to provide the cause of death to HM coroner.

I am very uneasy about post-op deaths PMs being carried out by people outside the hospital doing a £80 investigation. There is insufficient funding to do these PMs properly, "pile ‘em high and do them cheap" is not something I subscribe to.

Although my routine is to open the head and examine the brain I will not do so if there is a catastrophic COD such as a ruptured abdominal aneurysm. If there is a head injury the head will not be opened and the brain will not be removed until I am there to examine the body and carry out the PM.
I have a concern that clinicians refer to the coroner rather than requesting a hospital PM when this would be more appropriate - this then limits other tests such as histology that can be undertaken.

In hospital deaths should be treated separately.

Autopsy work in our department is extremely pressured due to only a minority of Consultants doing PMs (7 only doing >1000 adult, and 2 doing a supraregional paediatric service of >200/yr + 4 sharing neuropath ~ 75/yr). Maintaining high standards is difficult in the face of time pressure & training demands, as our juniors arrive from DGHs often extremely poorly taught & with little time to reach exam standard. Our clinicians often express their disappointment at the quality of work and reports from surrounding DGH's & I think this partly reflects time pressures in those centres.

We have a good coroner in terms of allowing histology etc, but the substantial pressures on the coroners officers also impact on our work. There are an increasing number of inappropriate Coroners PMs following Shipman, with GPs seemingly unwilling to sign up obvious cases, or 'away' or 'locum unable to sign off'. We also have a high workload of complex post-op and medical deaths.

I would give up autopsy work willingly, and it will not take much more pressure for me to do so. I disagree with colleagues who think this is done for money; its part of the job & training. I suspect some of them would rekindle an interest if the fee was doubled! The time & hassle involved are disproportionate.

I examine for the autopsy part of MRCPath and the general standard is low and getting lower. Autopsy 'lite' training will exacerbate this issue and create even more problems in future, unless the number of PMs decreases substantially or subspecialty training in autopsy pathology is introduced.

Routine histological examination should be a part of every full autopsy, whoever has requested it. Routine toxicology on every sudden death would also be very informative.

Clarification of above: 2 site department, I work on the site with 6 consultants. We have approx 16 trainees, with 4 at a time attached to us. All perform PMs.
Too much variability in different coroner's interpretation. We tend to get autopsies on complex medical cases and post op deaths. Very few 'easy' cases making time shifting very difficult. There is a clear interest to the trust (clinical governance) although they refuse to recognise them as part of our working day.
Under current constraints, it is not possible to perform a PM to the college standards, without taking a considerably longer time to do so, and thus making an unacceptably long working day/week.
Given the problems with consultant contract and non-recognition of PMs as an integral part of my work, I am currently considering dropping my PM practice.

HMC selects the wrong cases on which to perform examinations, due to the existing rules being inflexible, and the training and inclinations of the Coroner's Officers. 90% of cases submitted for autopsy do not need it, and are highly selected for IHD.

I feel strongly that Coroner's work should be included in Consultant job plan and general workload, and some agreement should be reached between Trusts and Coroners on this issue: post mortems have important implications on patient care and audit, even if (or especially if!) 'only' Coroner's case; post mortem outcomes are regularly reviewed by surgeons in NHS time; findings should be fed back to all clinical staff; post mortems very important in training, etc.

I do not work in a 'public mortuary', so most cases are complex and the payment is very small for the amount of time put in to these cases.

We desperately need HMG to define what is the exact purpose of an autopsy so that we can know to what standard one should pursue the cause of death i.e. 50% probability, natural causes or investigated to the molecular pathological level with auditable investigations?

Performing Coronial autopsies is becoming more unpopular, with more and more hassles associated e.g. HTA, relatives concerns, inquest duties, enquiries from interested parties. I believe the £93 fee is wholly inadequate for such an examination.

The time invested in performing even a straight forward post mortem is high compared to the remuneration, this includes the financial remuneration and the cost of time shifting. Most pathologists who do post mortems are likely to be spending more time than can be justified form the cost and time involved, but are doing it to maintain their skills and interest.

You assumed that I would be doing coroners and non coroners PMs in this survey but that is not the case.
I have answered in respect of non coroner's PMs.
My practise for coroner's PMs used to be similar however.

As a forensic pathologist who also conducts non-forensic coroner cases I believe there are too many "routine" cases, with not enough targeting that would allow more ancillary investigations (e.g. toxicology, histology)

It is becoming more and more of a hassle.

Very difficult to get new consultants to perform post mortems, therefore although 8 of us perform them. the new consultants will only do 1 or 2 a time and select straight forward cases. Therefore 3 of us do the bulk. Feel that they are very poorly remunerated compared with a cremation form. Little respect for those who do them. These can be very stressful cases and Pathologists and the impact on the pathologist of doing sometimes horrific cases is NEVER considered by the profession, managers or public body. These post mortems have to be done by someone and we will reach crisis point soon.
I believe that if post mortems are written into a consultant contract in the form of PAs NO-ONE will do them

The autopsies I do are on in-hospital deaths, or a few casualty failed resuscitations. I do/supervise a small number per year (30-40). The out of hospital deaths do not come through our hospital mortuary.
As histopathologists become increasingly sub-specialised in teaching hospitals, they are withdrawing from autopsy work, and it is increasingly difficult to give time/find people to do good training in autopsies. This will increase with time pressures from other areas of work. There is a growing inconsistency between standards of autopsy expected by the RCPath examinations, and wanted by coroners/public. Autopsy light training could concentrate the resource on a smaller number of genuinely interested trainees/trainers and seems important to introduce.

I will cease performing autopsies as soon as practicable.

I practise autopsies at a central mortuary (only hospital autopsies performed on site). This is associated with many problems including those related to mortuary staff.

I think we need to be prepared to make the case for retention of tissue for histology on a case-by-case basis if we are to do Coroner's autopsies to College standards. If no cooperation is forthcoming from HMC and his/her officers we must make sure that a statement about restrictions on tissue sampling rendering the cause of death inaccurate or incomplete is included in our reports. The recently published brief addendum to the Autopsy Guide from Sebastian Lucas and Jack Crane giving guidance on this is most welcome.

Trainees not getting sufficient experience.

Many clinicians now routinely refuse to request "hospital" autopsies because the consenting process is too lengthy and cumbersome.

MORE ACCURATE INFORMATION WOULD BE OBTAINED IF HISTOLOGY IS TAKEN MORE OFTEN. CLINICIANS ATTENDING THE DECEASED IF ATTENDING AT POSTMORTEM PROVIDES BETTER CLINICO-PATHOLOGICAL CORRELATION IN ISOLATED CASES. MORE INFORMATION IS BEST OBTAINED IN MOST CASES BY GOOD COMMUNICATION AND WORKING RELATIONSHIPS WITH CORONERS OFFICERS

This Questionnaire may not arrive at representative data, because it does not investigate widely ranging behaviour in one unit by a large number of consultants. The numbers here - apart from Total autopsies and the range of types of autopsies - are my personal data. I nearly always take histology, and do a lot of tox and microbiology specifically because of the case mix I am requested to examine. My colleagues have more 'routine' work and do far less investigation. I do not do perinates.

Overall, I think
1. we do too many coronial autopsies when they should be signed up with a reasonable MCCD
2. we do too few consented adult autopsies, as audit and QC
3. we do not generally investigate cases well enough because there is little or no demand from coroners to do so
4. I could go on for ever, as you might imagine; essentially we should be doing fewer but better

We are virtually the only country in the world where medico-legal autopsies (coroners) are not undertaken by trained and accredited medico-legal practitioners. In this modern day of increased litigation, reduced number of practitioners and more pathologists autopsy practice been scrutinised by the courts and GMC I am of the opinion that the autopsy service should be run by full time autopsy practitioners under the direction of the regional forensic group practices. That way they can incorporate the coroner, the new "medical examiner", non suspicious autopsy practitioners and the forensic experts under one cohesive professional service. The service should be funded and under full audit both external and internal with a proper management system, IT and accountants etc. The days of lone practitioners operating in mortuaries on their own should go especially if they are not doing the work themselves and the APT is doing the externals and eviscerations (which may be illegal - I would need to check this). only when we follow the rest of the world and have a properly funded service with the use of advanced radiology such as CT and MRI will our coroners service start to approach those of other major countries of the world and put the general publics mind at rest. The college should take a long look at places like the Victorian Institute of forensic medicine in Australia to see how the service should/could be run.

This is a complex area. There should be no double standard across the UK in my opinion, and the college must lead on this if it wishes to avoid more GMC cases reflecting poor autopsy practice.

I would like to know the result of this survey

Much as you would like it, there will never be enough forensic pathologists or resources to perform perfect autopsies.

I am actually a forensic pathologist so my practice is mainly suspicious/potentially suspicious cases and supervising mainly SPRs in FP on city mortuary work. I don’t believe under the current derisory funding system that much can be expected of most busy histopathologists in routine cases and some pathologists, even if paid appropriately(say £250 for a routine case and £450 for the current specials-to include high risk, decomposed cases, drownings, fire deaths, hangings etc)would still do a very poor job. Personally, in routine coronial cases, the key is differentiating the natural from the unnatural and potentially suspicious death. So not opening the head and not making a proper assessment of the anterior neck is inexcusable. Unfortunately this seems to be commonly the position, making the PM actually worse than useless and if concerns are subsequently raised, investigators mistakenly believe that head trauma and airway occlusion/neck pressure have been excluded. I have to say that I suspect that the majority of consultants practising coronial autopsy work have been inadequately trained/prepared for this type of work and once they take up post and join an autopsy rota don't feel they can admit to it. I have taught numerous trainees on the regional MRCPath course and always make the recommendation and offer for senior trainees even post exam to come and work with me for 4-6weeks prior to taking up post, so they have an idea of how to deal with bodies from water/fire, hanging etc. I've yet to be taken up on it.
A period of training like this should be a pre-requisite for independent coronial practice as should 300-400 autopsies during training.50-100 is a joke. And finally.....sorry for the rant...Has the College seriously considered who is going to do this work when the majority of trainees opt out of autopsy training? Forensic Pathologists (40 in England and Wales)will not be able to respond at all given the amount of existing suspicious autopsy work they are dealing with. Quite prepared to respond to College initiatives in this area.

Too many autopsies are performed on cases of clearly natural deaths for the coroner which either should have been certified by a "medical examiner" or to have had a consented autopsy to allow full investigation with detailed histology etc. I would gladly give up doing autopsies tomorrow, after 25 years experience!!

My trainees and new consultants are opting out of autopsy work, mainly because of poor remuneration.

College guidance seems to be constructed by those who imagine that all the average pathologist has to do each day is one or two autopsies; i.e. academics in ivory towers. Each day we have to weigh in the balance the many calls on our time; and take a sensible but flexible approach to each autopsy. My approach to sudden death in a 40 year old, is much different from that of say an 80 year old with ruptured abdominal aortic aneurysm.

Trainees will have problems with learning the value/limitations of PM histology, due to the constraints brought about by the HTA.

Paediatric pathology is very different to adult pathology, with all coronial cases being extensively investigated by radiology, histology, microbiology and toxicology, except in rare cases e.g. RTAs.
They are also so time consuming that we do them as if they are NHS work - if the Trust did not allow us to do this, I personally would not wish to continue with them, as the fee is insufficient to compensate for the time involved and stress with complex court cases.

Separate diploma for those who want to continue in autopsy work. To maintain a high standard in all autopsies.

An invaluable service but not enough time and resources and grave limitations due to the Human Tissue Act.

I am not sure that the right cases referred for Coroner's autopsy have a PM. I feel that there should be medical input into Coroners practice as to which cases should go on to PM. Sometimes I think the wrong cases are 'written up' when they should have had a post mortem.

A couple of questions do not allow sufficient flexibility in answering them. Regarding opening of bodies, the boxes are yes / no - I've ticked yes for both, but usually is the correct answer. My morticians have a general remit to open a body, but do not always do so - for example chest trauma, recent surgery etc.
I strongly believe that RCPath guidance in this (and other) areas is too prescriptive. The important outcome is that the post mortem report answers the right question, in the right amount of detail. There are many different ways to carry out an effective post mortem, and guidance should be broad rather than restricting. For example; a forensic style external is not required in most cases; a short CPC is acceptable in most cases - one can always expand on it if required to do so. The College guidance should be updated, be relevant to all aspects of post mortem practice and be properly evidence based. Epilepsy is a good example of this. The College guidance on deaths in epilepsy is well written and clear, but is badly referenced - there is no indication what elements of the guidance relate to which of the references. I'm sure very few people follow the guidance fully, unless they are lucky enough to have a neuropathologist on site (who is probably interested enough to do those cases anyway). I may be charged in excess of £1000 for a neuropathology report, which may take 6 months to arrive and often does not help anyway (changes secondary to epilepsy) and believe that to be a waste of money in most cases. Why can I not use my experience and discretion on how to investigate an epileptic death?

Now generally rushed and unsatisfactory as know that the more time I spend, the more time I will have to pay back doing NHS work.

Those performing autopsies for the coroner should obtain a diploma in medical jurisprudence. There should be fewer PMs done to a higher standard with an adequate history(provided by the coroner) and more toxicology testing.

SEVERAL QUESTIONS -
coroner numbers may be appropriate but some of the cases are not.
I examine the brain in every case unless there is a definite cause of death  i.e. ruptured AAA and there is no history of neurological problems

Yes you haven’t surveyed whether autopsies are included in job plan /contract or not. This is very variable.
I would like to stop doing HMC PMs as they are not in my contract, but there is no one local who would take them on.
Candidates for our vacant post do not want to do PMs any more

Coroner's cases need better selection and aims properly identified. Fewer done better rather than more done badly. Coroners system generally discourages trainees and most cases are now coroners cases, thus problem in training pathologists in autopsy work. This is made worse by lack of insurance cover for students/trainees at public mortuaries. Centralization means clinicians rarely attend autopsy, thus do not see benefit thus do not ask for consented autopsies etc. Downward spiral of autopsy practice. Poor understanding and DIFFERENT expectations of autopsy findings between coroners and pathologists.

Too many Coroners cases coming through; many of which are natural and could be written up. The RCPath guidelines are too prescriptive and do not take into account the large number of cases some of us have to deal with in a morning (I indicated on average 6 but some mornings there can be 15 or more)together with all the teaching involved of trainees and medical students. We have good technical staff (albeit too few of them) who are more than capable of assisting us with identification, evisceration and sampling. We delegate these responsibilities in other areas of histopathology so why not to autopsy practice? I do not propose we have 2 separate documents for Coroners work and consent autopsies - just one guidance from the College which is not so prescriptive.

The College guidance should specify if a Consultant pathologist or trainee is acceptable.

In my view the trainee is OK as these pathologists are as senior as those seeing and treating live patients in every acute 'take' in the country

Around 25% of coroner's cases in my area are not necessary other than to satisfy the 14 day requirement. These should be signed up and the resources given to more thorough autopsies on the rest.

RCPath should argue strongly against autopsies performed by those without appropriate qualification and experience : no Coroner's autopsy should be made without a qualification in forensic pathology .

RCPath must ensure adequate exposure and proper training in autopsy practice for trainees.

RCPath must argue strongly against performance of coroners' autopsies which do no more than provide income for pathologists.

I BELIVE THERE SHOULD BE ONE STANDARD, PUBLISHED BY THE COLLEGE AND ACHIEVABLE IN A CORONIAL SETTING AND THAT THIS SHOULD BE DETERMINED AT THE TIME OR FOLLOWING REFORM OF CORONIAL SYSTEM. THERE IS NO POINT IN SETTING NEW STANDARDS BEFORE THE GOVERNMENT DECIDES WHAT IT WANTS FROM THE CORONER'S SYSTEM, HOW MANY AUTOPSIES THIS IS LIKELY TO GENERATE AND HOW MANT PATHOLOGISTS ARE ULTIMATELY INVOLVED IN DELIVERING THIS SERVICE. WHEN IT IS KNOWN THE TIME AVAILABLE FOR PERFORMING AN AVERAGE AUTOPSY, THEN STANDARDS SHOULD BE DEVISED WHICH ARE ACHIEVABLE. THE CURRENT STANDARDS ARE NOT ACHIEVABLE IN THE CURRENT CORONER’S SETTING. I WOULD SUGGEST THAT HISTOLOGY BECOMES A STATUTORY REQUIREMENT AND THAT FEWER AUTOPSIES ARE ULTIMATELY DONE BETTER

The standard of many coronial autopsies in this country is poor. This is probably because the rate of pay is so low, so most pathologists cannot be bothered to do a better job, and it shows. I have the impression that the autopsy is frequently given a lower priority in the MRCPath than histology and I have got to the stage where I truly believe that there should be a special examination on autopsy and morbid anatomy which a histopathologist must have before they can do any autopsy work.

We perform very few autopsies, mainly on hospital patients. Coroners PMs performed in local Coroner's mortuary.
Far less interest from Consultant clinicians, although Juniors usually keen and enjoy correlation/teaching when they attend. Excellent teaching facility poorly used.

The number of PMs is steadily declining to a level where it may soon be difficult to maintain competence in some hospitals
There is little interest by most trainees
I suspect in the future that a smaller proportion of consultants will do PMs

What's adequate for the Coroner may not be adequate for the college/medical profession. Until the law changes that's just tough. There are not enough pathologists around to do the living's pathology, I'm not looking to make my life busier with unpaid-for work that satisfies medical curiosity.

Very poorly remunerated and we are becoming a dying breed, very few new colleagues want to be involved in the rigors of inquests etc.

We need to increase the number of consented PMs dramatically. I would prefer to do fewer cases for HM Coroner and more clinically relevant investigations.
For Coroners' cases, it needs to be easier to obtain permission to undertake histopathology. I used to do a lot - but very little now. If I find something that is incidental to the cause of death, it is a real rigmarole to get permission to take tissue for histopathology. That is a great shame.

There is a conflict sometimes between the information needs of the Coroner and the needs of clinicians/relatives which could be resolved if clinicians discussed and took consent from relatives, but there is a general reluctance amongst clinicians to discuss post mortem examination or take consent. P.S. where I have answered 0 cases per year it is because I mean less than 1

In this location the coroner regards the standard of autopsy practice as exemplary. We strive for excellence. We enjoy the work and find it stimulating and discuss cases amongst ourselves. When needed we seek information and help from other departments and also our coroner is very supportive and is readily contactable and eager to discuss a case and assist. Similarly, the coroner's officers are very helpful and understanding. We have six coroner's officers, one coroner, one deputy coroner and, I think, two assistant deputy coroners.

It was much easier before the HTA got involved!!!

Too many autopsies requested by HM Coroner on elderly adult non-suspicious but apparent sudden deaths in patients with known chronic diseases, where GP (usually, but occasionally also hospital team) "can't sign up"
Remuneration to Pathologists, and probably also to many NHS Trust for non-medical staff mortuary services, does not reflect the work required to perform autopsies to consistently high standards.
Would personally like to give up autopsy work but feel unable to do so as otherwise cases would not get undertaken.
Have concerns re poor standard of trainee pathologists in autopsy skill and interpretive experience (we have rotating trainees for 1 year of their regional training scheme) - does not bode well for future quality of Coronial autopsies.

My autopsy practice is entirely coronial now with very few hospital cases coming through, which tend to be done by junior medical staff in any case. The numbers coming through in our hospital are modest and the set up is such that the work is relatively easily slotted into the working day. 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.

The questions allow no room for answers other than those prescribed, thus severely limiting their usefulness.
Some of my practices are more or less forced on me by colleagues - e.g. removal of the brain by the technician when he thinks it apt, and leaving it out to deform, break into two and become virtually useless.
The question on limitations to taking samples would have been better expanded. The only thing I would take more of is histology, but our coroner refuses to allow, unless that histology is necessary in order to determine the cause of death (the histology is not paid for BTW).
We should be doing more autopsies. Hardly any hospital autopsies now. Most are done very quickly, for that is all that is needed. The college overkill recommendations are just plain absurd and pointless - just how much fiddling do people think is necessary to find disease?
I could go on .........

I am giving up all post mortem work next year as I am fed up with the continuous conflict between the Coroner's needs/wants, the HTA and the requirement to produce a professional and adequate report that satisfies all stakeholders' needs including the relatives. Relatively few of our autopsies are straightforward as we are not a public mortuary and the fee and the hassle are not worth it. We should be doing fewer autopsies done by fewer individuals who have a particular interest in the field and to a higher standard than is often the case at present. I think that those individuals undertaking autopsy work should be salaried with salary enhancement as part of their routine work. We are practicing autopsies 30 years behind the way we practice histopathology and it is time we brought it out of the shadows and into the light!

Needs to be done properly, recording all important findings, taking histology even if it does not affect the cause of death. Spend at least 1minute thought to give a proper comment at the end, explaining the clinical findings and correlation. A proper PM report (rather soon) gives a good feedback even if it is a road traffic accident where the A & E people and surgeons are involved. Anyway we are doing an autopsy which is difficult to accept by the relatives and others and spending the money.

Too many pathologists give a wrong cause of death because their coroner doesn't allow them to take histology. Pathologists shouldn't be bullied by coroners into giving a cause of death when they're not certain without histology/toxicology/microbiology.

In recent years, I have seen a number of NHS job descriptions with coronial autopsies included. I do not feel NHS appointments should be contingent upon willingness to perform coroners' autopsies as this may deter applicants for some posts (it has certainly deterred me). The College should ensure that participation in coroners' work (or non-NHS work of any kind) is entirely voluntary for NHS appointees.

There is a growing trend for post MRCPath trainees to stop doing PMS. With trusts becoming reluctant to allow in hours coronial PMs there will inevitable be a major shortage of competent pathologists willing to do out of hours/time shifted coronial cases .Locally there are a variable number who will cease doing coronial PMs. It seems to me that the college is producing half pathologists a bit like the R C Surgeons producing surgeons who don't do open surgery. It is likely to lead to autopsy specialists as even though there is a move to CAT scan or MRI scan PM substitutes these are not suitable for all cases and are even more post mortem to examination time dependent/limited. The immediate future is very worrying as I find coroners autopsies a real integrity test and one question that should have been asked is what is you unascertained rate. 2-4% is realistic and a 0% rate is nonsense.

"When is the head opened / brain examined?" Your question was badly designed. Sometimes I ask mortuary staff to take out the brain, sometimes to take off the skull vault and leave the brain removal to me, sometimes to saw the skull but leave the skull vault removal and brain and meninges removal to me. It depends on the history which I have always read the night before. Your question forced me to give one answer which therefore is not true.

All autopsies are limited to some extent. How limited an individual examination is depends partly on clinical indications and partly on the pathologist. The College guidelines must be realistic in setting minimum standards of practice, otherwise they will be ignored. For example, to say that the brain must be examined in all cases ignores the fact that in some instances (e.g. haemopericardium, ruptured aortic aneurysm) it is totally unnecessary in diagnosing the cause of death. My experience of reviewing Coroner's autopsies is that many are performed to a very poor standard. A joint document from the College and Coroner's Society may help to improve this situation by increasing the expectations of Coroners and making it clear to them when they are receiving a sub-standard service.

See my comments above. We should accept that technical staff qualifications are sufficient for them to begin the PM once the case has been discussed with the pathologist and without the pathologist first viewing the body...unless the technical staff observe anything they are unsure about.

There is too much pressure to give a "medical cause of death" without taking adequate samples in many Coronial practices.

We are often asked to make complex neuropathological diagnoses without keeping the brain because of a Coronial desire not to delay funeral arrangements.

I think the performance of Coronial autopsies should be in the job plans of all pathologists, with no opting out, and that we should be paid by the NHS for this work directly through PAYE rather than being in the ridiculous situation of being regarded as self employed by HM Customs and Revenue and having to pay higher rate NI contributions and employ an accountant to complete tax returns. This also has the knock-on effect of us having to "employ" our own secretaries for typing and our lab staff for cutting sections etc so we indirectly become "employers". This system is far too complex.

Also, the present system encourages pathologists to perform many "rapid" post-mortems to gain the maximum fee (often as many as 8/morning) but these are often poorly done and are clearly not performed to RCPath guidelines. The fee offered per case, when translated to a fee per hour, is so little that many pathologists prefer to do private surgical work and refuse to participate in autopsy rotas.

Good rapport and understanding with the coroner is important as it makes life easier for both parties.
More freedom to take histology.

Standards are low as confirmed in NCEPOD report.
Autopsy practice is not considered to be a NHS activity and therefore is not funded like the rest of histopathology practice.
Unless the matter of resource is addressed this will keep getting worse.

It is a pity that the C.O.D cannot be updated in the light of subsequent information; e.g. proper classification of a tumour or addition of other unexpected relevant finding. We used to do "pink forms". Now I think the Coroner completes them on our behalf when the supplementary report is received. A file note is added, but I believe that the registered C.O.D is unalterable (non-inquest cases, that have been closed.)

There should be fewer, but better paid, coronial autopsies. That should allow more time to do them better, and might encourage more of my colleagues to do them!

Not enough resources, i.e. NHS workload is very heavy, little time left for autopsies

I think the College should allow trainees who are not interested to drop autopsies so the remaining interested trainees get more practice.

1. The vast majority of non-forensic coronial post mortem cases should have been certified by the attending clinicians/GPs. 2. I am currently considering whether to withdraw from autopsy work because of a) excessive demand for autopsies b) inadequate circumstantial information from coroner's office c) lack of any respect of my clinical time by the coroner's office d) RCPath Autopsy Guidelines set too high a standard for the time available e) HTA standards unrealistic f) too many requests for attendance at inquests g) fee paid after deductions and tips is not commensurate with the time involved h) perception of recent significant increase in clinical risk issues i) too many colleagues in my department have already chosen to not participate in autopsy duties and j) it is becoming increasingly difficult to justify the time shifting and minimal disruption of NHS duties stance to management.

Difficult to answer survey without distinguishing between Coroners and Consent PMs as practice is very different

Far too many pointless coroner's autopsies. We should be doing fewer to a better standard. I particularly object to obvious natural disease deaths in the elderly (including several centenarians I have been obliged to do recently!) Better vetting of cases is needed to reduce the pointless ones. A medical coroner might help. There appears to be so much worry about all this post Shipman that the situation is getting out of hand and needs a dose of common sense. Pathologists could be best placed to help with this - perhaps a new/extended role for us.

Coroners autopsy are many a time not done satisfactorily due to the fact that histology can't be taken because the cause of death is already there and the coroner is not interested in knowing the other things which the pathologist is interested in. As a junior consultant I would like to take more histology.

Coronial variations in practice effectively mean that some RCPath guidelines are unachievable, others represent best practice but all allow for individual case variation. We cannot surely lower our standards of practice to fit in with coroners who want a fast, minimalist service without any regard for accuracy or relevance to families or others. Instead of changing our practices we should be fighting for uniformity of autopsy services across the UK - if we cannot follow best practice then we should state in our reports how we were prevented from doing so - this we do when histology is refused by our coroner

I am a great believer in the autopsy as a valuable tool for audit and education over and above the Coronial field. Clinicians too readily trust the imaging and clinical findings and don't think to request an autopsy. We must not allow further devaluation of the autopsy and we urgently need revision of the Coronial legislation to enable Coronial work to be carried out to a consistently high professional standard in all cases, including permission for and funding of histology when deemed necessary by the PATHOLOGIST. We need consistency of approach by all Coroners and less "Coronial discretion" which in our region is essentially fiscally driven. We often find ourselves in the difficult position when completing cremation forms on cases that have actually been through the Coroners Office, of having to bounce cases back to the Coroner because they have been "Pink A’d” with a potentially unnatural or at least uncertain cause of death!

Without routine histology and standard reporting forms the standard of the Coronial post mortem is suboptimal but then the remuneration for a complex and sometimes unpleasant task is pathetic.

The inability to take samples to confirm a natural C of D can be a problem and as the junior doctors have had less experience will become an increasing problem