The slow death of the clinical post-mortem examination: implications for clinical audit, diagnostics and medical education

Abstract

Many clinicians are unaware of these events, which may come to have wide-ranging detrimental effects. One possible cause is the lack of training of junior medical staff in obtaining consent for postmortem examination, though other factors are also important. KEY WORDS: audit, autopsy, decline, diagnostic errors, post-mortem examination IntroductionPost-mortem examinations (PMs) have been important in the development of modern medicine, their value having been recognised for about two centuries. 1 PMs of hospital patients should continue to be valuable in clinical governance by providing an independent means of checking the accuracy and completeness of ante-mortem diagnoses and an assessment of the effects of treatment. Indeed, a programme of well-conducted clinical PMs forms the heart of a method of quality assessment of medical diagnostics. 2 Additional benefits include: a greater understanding of disease and its management; the description of new diseases or the effects of new treatments; 3 the retention of tissue and organs for teaching and research; the training of medical students, 4 junior doctors and histopathologists; 3 and continuing professional development of clinical consultants. They also increase awareness of the multiplicity of conditions which many patients (particularly the elderly) have and of the level of uncertainty -'necessary fallibility' -in medical practice. [4][5][6] Moreover, the greater understanding following PM may also be beneficial for the family, 7 something that should not be overlooked when the recently bereaved are counselled by clinicians. This is particularly the case in pregnancy loss and possible inheritable disease, where there may be important implications for other family members.It has long been recognised that the clinical (consented) PM is in decline 1,5,[8][9][10][11][12] and, if not dead, then terminally ill. 13 In Britain, this decline appeared to start in the 1950s 8,12,14 and has continued ever since. There are, however, few recent data to support this contention, and the effects of the publicity following events in Bristol and Liverpool have not been explored. Here we describe the recent consented PM rate for patients dying in the Norfolk and Norwich University Hospital NHS Trust (NNUH), which has 989 beds and serves a population of at least half a million, and the nature of the consent given. We also explore clinicians' opinions about the numbers of PMs they request and how they obtain the necessary consent. Methods Review of the numbers and extent of consented post-mortem examinationsWe examined the records of the mortuary and Department of Histopathology for the period 1 January 1996 to 31 December 2003 to determine the number of adults dying in NNUH, the number undergoing consented PM, and the extent of the examination permitted by that consent. From these data we derived the clinical PM rate (number of consented PMs divided by the number of deaths, expressed as a percentage). The number of stillbirths and perinatal deaths, the number of consented PMs undert...

Reversing the slow death of the clinical necropsy: developing the post of the Pathology Liaison Nurse

“…19 During 1996-2003 Norwich followed the general trend, with the reduction of adult clinical necropsies being approximately linear. 20 While the publicity surrounding events in Bristol and at the Alder Hey Hospital seemed not to alter the rate of decline of the adult clinical necropsy, we noticed a detrimental effect on the extent of examination permitted by families. There were substantial effects on both the clinical necropsy rate and the extent of examination in perinates and neonates.…”

“…There were substantial effects on both the clinical necropsy rate and the extent of examination in perinates and neonates. 20 We wished to reverse the decline in adult clinical necropsies, not only for the reasons noted above but also because of the needs of the newly established medical school based at the University of East Anglia 21 and to assist in training our histopathology senior house officers and specialist registrars. We thought that the demand on clinicians' time in completing the documentation for necropsy was one factor in the decline in the clinical necropsy rate.…”

Factors Associated with Stillbirth Autopsy in Georgia and Utah, 2010–2014: The Importance of Delivery Location

“…It is of particular concern that the stillbirth autopsy rate may be decreasing over time, as has been reported in Europe. 11,26 A potential contributing factor to the decline in stillbirth rates during the study epoch was the Stillbirth Collaborative Research Network study conducted from 2006 to 2008. 27 This study enrolled stillbirths in Salt Lake County, Utah, and DeKalb County, Georgia, and included promotion of the benefits of autopsy as well as access to perinatal autopsies at no cost.…”

Over-regulation of clinical research: a threat to public health

“…Furthermore, too much detail may well distress the bereaved unnecessarily. As a result of this complexity, the number and extent of post-mortems have declined, 28 pathologists have been vilified, diagnosis is compromised, audit and clinical governance suffer, and research withers. Teaching withers too; in New Zealand, students have even been banned from attending autopsies.…”