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I am grateful to Dr Roberts and colleagues for their important paper and argument to formulate guidelines on when to report a death to the coroner and decisions thereafter.1 This has important implications for practitioners in primary and secondary care. One particular dilemma is when to discuss with the coroner what appears to be a natural death, but where the cause is unknown or where the patient is well known to the practitioner, but has not consulted in the required preceding 14 days. This is compounded by the variation in attitudes of coroners and their officers to such discussions.
It is indeed a “grey area” where agreed guidelines are required for doctors and coroners so that it can be determined more precisely when necropsies and inquests are required. To facilitate this process, death certificates and the second part of cremation forms could comprise specific additional questions. These should ascertain the extent to which the certifying practitioner, and the independent practitioner in the case of a cremation form (part 2; form C), are in agreement that the cause of death stated is beyond reasonable doubt, and so whether or not involvement of the coroner is required. In the case of cremation, where a body is permanently disposed of, the use of a second practitioner who discusses the case with the first practitioner incorporates a double check into the process. This check is supplemented by a third practitioner acting as the crematorium medical referee.
It is well known that most medical diagnoses are made through clinical history, examination, and investigations, so that in most situations unnecessary distressing necropsies and inquests could be avoided, although they may be required given the existing regulations.
Guidelines should be aimed at improving the specificity of the postmortem service as a research tool to be of benefit in three ways when the cause of death is unclear, namely: (1) educating the profession, (2) ascertaining where death is unnatural, and (3) most importantly, facilitating the grieving process of relatives. The latter could be facilitated by next of kin clinics, which have been discussed in this journal,2, 3 and which target the needs of families attempting to come to terms with the complications of a coronial investigation at a time of crisis, particularly in the situation of sudden death. Such changes should not only improve the quality of the service and its clinical effectiveness, but also be an aid to clinical governance in this area.
The authors reply
Some years ago, and on the basis of no evidence whatsoever, we suspected that general practitioners were not interested in the outcomes of necropsies. However, and to our great satisfaction, a questionnaire study1 demonstrated that this view was clearly wrong. Dr Charlton provides further support for the necropsy from primary care, and our pleasure knows no bounds.
We fully support Dr Charlton's suggestion that pathologists should talk to relatives, and we often do so, on an ad hoc basis, after inquests, etc. However, in most hospitals, including ours, there are not enough histopathologists to make routine interviews with relatives a realistic proposition. At the moment, we would prefer this task to remain with general practitioners.1
Necropsies and inquests have many functions beyond simple confirmation or refutation of clinical diagnoses. We agree that they might be usefully aimed at different targets, but we would take issue with Dr Charlton's assertions that many necropsies could be avoided because the diagnosis can be made before death. Clinicians can make correct diagnoses in most cases, but discrepancy rates between clinical and postmortem diagnoses remain woefully high, even when the clinicians are confident about their diagnosis.2 Much might be said for a system where control over the selection of which cases are referred to the coroner, or for hospital necropsy, is removed from those in charge of the subjects before death.
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