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The paper by Rutty and colleagues1 fails to focus upon the key issues raised by the question it seeks to answer. Those issues are: (1) What is the “primary purpose” of coroners’ necropsies? (2) Is the “information available at the time of necropsy” adequate? (3) What is meant by postmortem examination? Does it only mean dissection of the whole body? (4) Under what circumstances should a necropsy be performed without regard to the views of the next of kin?
In our view, this last issue is the most important and other issues should be dealt with within that context: none of these issues can be dealt with meaningfully without informed public debate. The authors pay lip service only to this question and reach a conclusion “ . . . we consider that necropsies still have an essential role within the coroner’s enquiry” that is self evident but superficial.
The paper seems to be based on a false premise—that the “view and grant” facility could replace necropsies. In this study, the causes of death were predicted in 61–74% of cases; in Glasgow, view and grant is performed on approximately 10%2 of the deaths with which the department of forensic medicine is concerned. This procedure is regarded as an “alternative”, an adjunct to detailed review of the circumstances of death, allowing deaths where there is no suspicion or evidence of criminality to be certified without a necropsy.
The authors acknowledge that “the most important” factor in a pathologist’s ability to “predict a cause of death before necropsy” is “the quality of the information available to the pathologist”. However, there is no assessment of the quality of information provided in this study, despite a publication by one of the authors3 indicating the relatively poor quality of such information. A key question raised is: “Was there, in fact, no clinical information available or was the absence of information a reflection of inadequate enquiry on the part of the coroner?”. The paper does not deal with that question but, sadly, ignores it with the following dismissive statement: “Any additional information concerning the deceased, which subsequently became available after the necropsy, was not included, because this could have caused bias in the second part of the assessment”. This appears to us a sad inversion of the importance of the issues.
The inference may be drawn from the paper that where adequate information was provided, allowing a prediction of cause of death, then “the number of correct predictions made of those where a cause of death had been proffered were as follows: A, 70%; B, 63%; C, 59%”. This appears to us to be the “true error rate”, reducing itself to 30–41%, as opposed to the authors’ preferred 54–61%; we would maintain that one should not include in any determination of “error rate” those cases where a prediction could not be made because of inadequate information: under the view and grant system a necropsy would have been carried out in such cases.
In a paper that attaches so much importance to accuracy of cause of death, it is doubly distressing to find a lack of precision in attributing death to “ischaemic heart disease” without further detail of the pathological basis for ischaemia and in finding “bronchopneumonia” an adequate explanation of death.
We think it unfortunate that this paper does not distinguish between the populations of “natural death” and “unnatural death” or give an indication as to whether any of those deaths that were considered to be natural before necropsy were shown to be unnatural—it is this distinction that appears to us to be the primary purpose of a system of investigation of death in which the wishes of the next of kin are irrelevant.
We welcome the opportunity afforded by the authors to add to the debate regarding the role and future of the coroner system. The authors’ implicit support for more detailed investigation of the circumstances of death before postmortem examination sits well with the “radical option”—foreshadowing a “medical examiner” system—detailed in the Home Office consultation document produced in the first phase of its Review of Death Certification, and with recommendation 11—”the feasibility of establishing a new system of death certification involving a medical examiner should be explored”—in recent advice from the chief medical officer.4