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The (possible) Future of Autopsy

The (possible) Future of Autopsy. Dr R Hadden Consultant Pathologist Derriford Hospital Plymouth. How has the Autopsy changed in the 21 st Century?. Public. Coroner. Pathologist. The Anatomy Lesson of Dr. Nicolaes Tulp - 1632. The Anatomy Lesson of Dr. Deijman - 1656.

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The (possible) Future of Autopsy

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  1. The (possible) Future of Autopsy Dr R Hadden Consultant Pathologist Derriford Hospital Plymouth

  2. How has the Autopsy changed in the 21st Century? Public Coroner Pathologist

  3. The Anatomy Lesson of Dr. Nicolaes Tulp - 1632

  4. The Anatomy Lesson of Dr. Deijman - 1656

  5. Coroners Statistics 2010 England and Wales Ministry of Justice Statistics bulletin • 101,900 101,900 44% of reported deaths

  6. 89,206 (-1% on 2014) • 38%

  7. Pathologist • Variable Quality and limited quality control • The Coroner’s Autopsy: Do we deserve better? 2006 • Poor-unacceptable in 26% • Human Tissues Act • Diminishing workforce + under funding • RCPath – Certificate of Higher Autopsy Training • Optional post-ST2 • Published Standards • CT autopsy • Hutton Review

  8. Coroner • Coroners and Justice Bill 2009 • Chief Coroner • Coroners must be legally qualified +/- medical • Introduction of Medical Examiner System

  9. Public • Bristol • Alderhey • Faith communities

  10. Medical Examiners • Recommended by The Shipman Inquiry, Francis Report (2013), Kirkup Report (2015), Hutton review (2015) • Robust scrutiny of circumstances and cause of death in all apparently natural deaths (i.e. those not investigated by the Coroner) • Improve quality of death certification • Offer relatives an opportunity to ask questions/raise concerns • Provide feedback for quality of care assurance systems • General medical advice to Coroners • Collate and share statistical information Coming in April 2018!!

  11. Table 1: Initial aims of death certification reform • To ensure rapid referral to the coroner of any death where there are reasonable grounds to suspect that death may not be entirely due to natural causes • To avoid referral to the coroner of deaths where such referral is unnecessary • To provide a non-coronial route to certify deaths that are clearly due to natural causes, but where a doctor able to sign an MCCD is not available • To improve the accuracy of certified causes of death • To collect and report information on clinical governance issues identified during scrutiny • To ask the next of kin whether they had any concerns about the death that might justify further action (subsequently referred to as ‘The Shipman Question’) • To answer questions from the next of kin • To educate health service staff in matters relating to death certification

  12. Effect on Coronial proceedings • Slight increase in inquests (approx. 5%), following scrutiny • Total deaths referred remained static, or showed a slight reduction. • Due to filtering of inappropriate referrals • Non-coronial route of certification when coroner believes death due to natural causes but no doctor qualified to complete MCCD.

  13. Hutton Review • Meant to review the forensic service • Ended up encompassing coronial service • Too many mortuaries not enough pathologists (in the future) • Centralisation of death investigation (15 centres, previously 30 centres) • National Death Investigation Service • ?establish a Special Health Authority • Lead by Forensic pathologists • To become part of NHS work?

  14. CT Autopsy • Joint statement by the RCR and RCPath • Validated, including angiography for IHD + PE Lancet. 2012 Jan 14;379(9811):136-42 • 2015 Legal precedent for requesting CT in place of invasive PM (with understanding that invasive may still be needed)

  15. Images from Ian Roberts’ Presentation:Imaging Techniques and cardiac autopsy

  16. CT Autopsy • Who reports? • Where and with what resources? • Who pays? • Logistics (body transport, scanning, return to autopsy centre?)

  17. CT Autopsy • Radiologists trained in autopsy CT • Pathologists make final decision on COD +/- autopsy • Proposed regional centres (SW potentially in Bristol!) • Privately funded centres or use of NHS resources out of hours • Paid for by charities/family or local authority • Costs several hundred pounds vs £96.80 for standard PM

  18. So What is The Future?! • Uncertain • Both RCPath and Hutton expect fewer autopsy pathologists in next few years • Centralised mortuaries, with dedicated CT scanners lead by forensic pathologists with a team of coronial pathologists working as part of the NHS! • Medical examiners scrutinising all non-coronial deaths ? More appropriate coroners referrals

  19. Probable outcome: • Minimal changes • Decrease in autopsy rate following introduction of medical examiner • CT a long way off, until someone makes it cheaper than an invasive autopsy and gives us a scanner

  20. Links: • Hutton Review • BAFM response to Hutton Review • RCR/RCPath Statement • The Hutton Review of Forensic Pathology, Imaging-based Autopsies and the Future of the Coronial Autopsy Service – A Commentary • Reforming death certification: Introducing scrutiny by Medical Examiners Lessons from the pilots of the reforms set out in the Coroners and Justice Act 2009

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