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[This edited version of the report has been prepared by Dr Robert N Moles]

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In September 2004 the British Medical Journal reported that the UK was to establish an audit to review pathologists' reports on adult autopsies.

The report said that the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) which was an independent UK body that does audits designed to assess and improve patient care had announced that it was to review reporting procedures for adult autopsies ordered by coroners. The study was to assess the quality of pathologists' reports on adult autopsies requested by coroners, which account for 90% of postmortem examinations in the United Kingdom. It was said that it would include all autopsies done during a one week period during 2005 in the regions covered by NCEPOD in England, Wales, and Northern Ireland. Independent reviewers from NCEPOD were to assess the autopsy reports against guidelines developed by the Royal College of Pathologists. They were then to make recommendations to inform future practice and guide development.

The report said that the study had been proposed by the Royal College of Pathologists after concerns about the quality of reports on autopsies ordered by coroners, which have generally been considered to be less thorough than autopsies requested by hospitals. It said that autopsies are ordered by a coroner for people who have died unexpectedly or suddenly, who had not seen a doctor in the two weeks before death, or who died within 24 hours of admission to hospital. Autopsies are requested by hospitals for patients who have died after having had treatment during a hospital stay if there is some question about the cause of death.

Christobel Hargraves, chief executive of NCEPOD, was reported to have said, "There has been a marked difference between the quality of autopsies performed by pathologists based on a request from a hospital and those ordered by a coroner. Previous studies have shown that around 30% of coroners' autopsy reports do not give an accurate description of the death or what caused the death."

The report said she suggested that this was because pathologists carrying out these autopsies had not looked at the patient's case history or had not done a sufficiently thorough examination of the body. This difference was noted in the Shipman inquiry (into the deaths of patients murdered by the general practitioner Dr Harold Shipman) and in an inquiry by the Home Office, which resulted in measures designed to reshape the coroner's services.

Source: Susan Mayor - British Medical Journal 4 September 2004; 329(7465): 527

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