Hospital autopsy: Endangered or extinct? | Journal of Clinical Pathology

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Hospital autopsy: Endangered or extinct?

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Medicolegal quasi-hospital autopsies
Richard Y. Ball
Published on: 18 April 2016

Published on: 18 April 2016
Medicolegal quasi-hospital autopsies
- Richard Y. Ball, Histopathologist
The paper by Turnbull and colleagues (1) on the decline of the adult hospital autopsy rate in UK prompted me to review and extend the Norwich data that they kindly quoted (2). I calculated the adult hospital autopsy rate since our publication (including that relating to the first five months of this year) using the method that we both employed. The modest improvement that we reported in the adult hospital autopsy rate i...
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The paper by Turnbull and colleagues (1) on the decline of the adult hospital autopsy rate in UK prompted me to review and extend the Norwich data that they kindly quoted (2). I calculated the adult hospital autopsy rate since our publication (including that relating to the first five months of this year) using the method that we both employed. The modest improvement that we reported in the adult hospital autopsy rate in Norwich between 2003 and 2005 was not subsequently sustained and the overall trend continued downward. During the period since 1 January 2006, the mean adult hospital autopsy rate in Norwich was 1.1% (range 0.1%-1.7%). The rate in 2013 was 0.6%, in line with the data presented by Turnbull et al. (1).
During 2006-2014, there has been a rising trend here in the annual number of autopsies undertaken for HM Coroner (mean 1191; range 1037- 1355). Most such cases represented deaths in the community or in the A&E Department, but some were patients who died in the wards after admission. In such cases the attending clinicians were unable to complete a certificate of the cause of death. While some such cases followed trauma or other unnatural events, many were natural deaths in which the clinical course was difficult to understand, sometimes despite detailed examination and testing; no confident diagnostic label was attached before death. Such Coroner's cases arising from within the hospital patient population represent medicolegal quasi-hospital autopsies and provide a partial means of alleviating the decline in consented adult hospital autopsies. It is my experience that many such cases provide valuable opportunities to study disease and the efficacy of diagnosis and treatment in the hospital setting.
The continuing decline of the adult hospital autopsy is of great concern. It is likely to multifactorial and to be influenced by the attitudes of clinicians, pathologists and bereaved families (3,4). It does have important implications for clinical audit, diagnostics and medical education (3). While such matters can, at least in part, be addressed by the coronial autopsies that are undertaken on certain hospital deaths, such cases are relatively few and do not necessarily reflect the normal population of patients who die in hospital; they are likely to provide a skewed experience. We know little about the numbers of such cases or what stimulates a clinician to discuss a seemingly natural death with the Coroner, rather than to use clinical judgement and suggest the most likely cause of death and complete a death certificate. It may be that clinicians wish to have a greater degree of certainty than such an approach allows.
While medicolegal quasi-hospital autopsies are an imperfect substitute for properly conducted hospital autopsies, they are better than nothing and should, perhaps, be considered when assessing adult hospital autopsy rates. The whole matter clearly requires further research. Autopsy practice in general is threatened by the decline in the numbers of histopathologists who are prepared to undertake any such examinations. That itself is a matter of concern and requires deeper understanding and rectification. It chimes with Byard's view that the decline in the autopsy is, at least in part, the responsibility of histopathologists (4).
References
1. Turnbull A, Osborn M, Nicholas N. Hospital autopsy: Endangered or extinct? J Clin Pathol Published Online First: [15 06 2015] doi:10.1136/jclinpath-2014-202700
2. Limacher E, Carr U, Bowker L, et al. Reversing the slow death of the clinical necropsy: developing the post of the Pathology Liaison Nurse. J Clin Pathol 2007; 60:1129-34.
3. Carr U, Bowker L, Ball RY. The slow death of the clinical post- mortem examination: implications for clinical audit, diagnostics and medical education. Clin Med 2004; 4:417-23.
4. Byard RW. Who's killing the autopsy? A new tool for assessing the causes of falling autopsy rates. Med J Aust 2005; 183:654-5.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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