Examination of Witnesses (Questions 180-187)
DR MICHAEL
WILKS, DR
JOHN GRENVILLE,
DR ANNE
THORPE AND
DR ANDREW
DAVISON
20 JUNE 2006
Q180 Julie Morgan: Turning to the
autopsy rate in England and Wales, this is also very high compared
with other jurisdictions. Why do you believe that is so?
Dr Davison: I would refer to my
answer to the first question. I referred to the 14-day rule and
the amount of information that is gathered prior to that decision
being made. This is crucial. The Royal College of Pathologists
has said many times that one of the main problems is the lack
of information provided to the coroner and so to the pathologist
before the decision to perform a post-mortem is taken. For instance,
there is nothing like a typed sudden death report in England and
Wales. Sometimes in non-suspicious deaths we will receive, if
we are lucky, a typed history from the coroner. Usually, it is
a handwritten scrawl. I have experience of cases such as road
traffic collisions where all the history I get prior to the post-mortem
is: "Deceased involved in road traffic accident. Taken to
hospital. Died." That is almost useless and it does not serve
the family well to have a post-mortem done for that reason. Neither
the coroner nor the pathologist is served by that lack of information.
Part of the problem is that coroners' officers do not on the whole
get out of their office. Some do but not many; a lot of them are
deskbound. They do not get out and chat to the relatives; usually,
the relatives have to go to them.
Q181 Chairman: The problem with the
14-day rule will become worse because of the number of doctors
who will not have seen the patient either because it involves
a doctor with an increasingly large practice or it is outside
the nine-to-five contract, or whatever it is—if you forgive
me for saying so—and an agency doctor is involved?
Dr Davison: That is another minor
factor. I suppose that another problem is that doctors are, post-Shipman,
slightly worried that relatives might accuse them of doing something
improper. That encourages them to refer more cases to the coroner
so as to be seen not to be doing anything improper. Dr Grenville
may want to comment on whether or not the changes in the GP contract
or the way general practice works have an effect.
Dr Grenville: I am not convinced
that it is the changes in the GP contract but the way that we
look after patients. There is much more teamwork and there is
a much wider team nowadays. While the doctor may be co-ordinating
things he may not be seeing the patient on a day-to-day basis.
The district nurse and the community matron may be the ones who
go in and see the dying patient. This is particularly so in cases
where patients have long-term illnesses that are in the terminal
phase. The doctor will try to get there, but he may be on holiday.
However, the care will continue. The doctor will be the central
point and have the record. He may be the person who is best able
to synthesise what has gone on and come up with a reasoned opinion
as to the cause of death. In this sort of situation it should
be fairly obvious anyway, but he may well not have seen the patient
in the past 14 days.
Q182 Chairman: So, there will be
more referrals and more autopsies?
Dr Grenville: Under the present
rules, yes. We need to be able to get round that and say that
information is important, not sticking to the rules. If we believe
that we have gathered high-quality information in a reasonable
way then we can make high-quality decisions. Just having stuck
to the rules does not necessarily mean that the decisions will
be of high quality.
Q183 Julie Morgan: Is there a lack
of trained pathologists in England and Wales?
Dr Thorpe: Perhaps not everyone
here knows what a histopathologist is. Autopsies in this country
are done by histopathologists who do two things. They are concerned
with the diagnostic reporting of biopsies and surgical specimens
and they are also trained how to carry out autopsies and interpret
the findings. There are about 1,600 histopathologists in the UK.
According to figures provided by the Royal College of Pathologists,
this year there are about 200 vacant posts, which is approximately
14%. That in itself indicates there is a shortage. Another factor
to consider is the age distribution. About 40% of histopathologists
are 50 or older. You may wonder what the implication of that is.
Since Bristol and Alder Hey the number of hospital-consented post-mortems
has dropped dramatically. My hospital is probably typical, in
that we used to do about 200 a year and now we do about 20. The
training opportunities have dropped. The College put a figure
on how many post-mortems a trainee should do per year, which is
currently about 20. When I and my colleagues trained it would
have been very unusual for someone to do less than, say, 60 or
so a year. Obviously, there was no need for any guidance about
numbers. Therefore, younger pathologists and ones coming through
training get their first consultant post with a good deal less
experience in carrying out autopsies than we did. I suspect that
fewer of them will be willing to put themselves in the medico-legal
position of carrying out coroners' autopsies, attending inquests
and possibly being questioned by barristers as to their findings
when they are not really very experienced. I believe that the
age distribution is an indication that a shortage of pathologists
to carry out post-mortem examinations for the coroner will be
a problem in the future. Within the Royal College of Pathologists
there is an active discussion about the concept of "autopsy-light
training" in which trainees could self-select themselves
into groups that want to become confident in autopsies and those
who really do not want to go down that route but stick to diagnostic
surgical pathology. Clearly, that would further reduce the pool
of pathologists who would be willing to undertake this role. There
is a problem of manpower, which I believe will get worse.
Q184 Julie Morgan: Is this having
an effect on the death investigation system?
Dr Thorpe: I do not believe that
it has started to have an effect on what might be called run-of-the-mill
coroners' post-mortems. There is certainly an effect on specialist
types of coroners' post-mortems, particularly paediatric post-mortems
and ones requiring skills in neuropathology and complex trauma
cases. I am sure that Dr Davison can think of more examples. I
am sure that there will be a much bigger problem than we are aware
of now.
Q185 Julie Morgan: The BMA has accepted
the concerns expressed in the Luce Review about the quality of
some coroners' post-mortem examinations. Would the new provisions
in the draft Bill allowing bodies to be moved to areas where there
is appropriate expertise address the concerns about quality?
Dr Thorpe: From my point of view,
that is a good development. Maybe others want to speak about quality.
One thing that struck me about the proposed role of the medical
examiner or medical assessor proposed by Tom Luce and Dame Janet
was that that was an opportunity for somebody to audit the work
done for the coroner by the pathologist and make sure that the
standards set by the Royal College of Pathologists were broadly
adhered to. My sadness about the local medical advice now being
on a rather ad hoc basis is that it is not specified that a person
would be responsible for assuring the quality of post-mortems
in a coroner's jurisdiction.
Dr Davison: To comment on the
issue of quality, it would certainly help if bodies could be moved
to certain specialists areas but I would not like to see it as
a wholesale option. Part of the problem is that it can be difficult
to identify exactly the problem until one has started the post-mortem.
I can accept that certain cases can be identified. Paediatric
cases are an obvious example, but there are other cases where
one does not really know which expertise is required until one
starts the examination. For the vast majority of cases I do not
believe that the bereaved families want bodies moved a great distance
away to a specialist in a big centre. I believe that is of limited
value. Anecdotally, there are concerns among pathologists about
the quality of a significant minority of post-mortem examinations.
The scale of that significant minority we cannot judge. NCEPOD,
which used to be the National Confidential Enquiry Into Peri-Operative
Death but is now the National Confidential Enquiry Into Patient
Outcome and Death, started in 1989. As the title suggests, it
looked at peri-operative deaths and found that in about one quarter
of cases the pathology was regarded as poor or unacceptable. The
outcome of those reports over the years improved that figure somewhat
but not much. The Royal College of Pathologists proposed to NCEPOD
two years ago that they would do an audit of coroners' autopsy
reports. That is the first time it has ever been done. That report
will be published on 18 October of this year. I was an adviser
to that study but I cannot speak about any of the findings because
it is embargoed until then. I have seen a first draft. I believe
many of the recommendations may be of very great interest to this
Committee. It may be that you can approach NCEPOD for perhaps
sight of a draft or an earlier release in confidence.
Dr Grenville: As to quality, we
should remember that that does not end with the post-mortem examination.
A report is generated. I think the quality of the whole system
could be improved considerably if the coroner's post-mortem report
was routinely made available to the patient's registered GP. Clearly,
most cases are reported to the coroner because the cause of death
is uncertain. The GP is one person who needs to learn what cause
of death has finally been decided upon and why, so he can use
that information to learn from it or change practice where necessary
in future. It is part of "an organisation with a memory"
and the continuous learning process.
Q186 Julie Morgan: What about helping
relatives to understand the implications of a report? Do you think
that is the role of the GP?
Dr Grenville: I believe that it
is vitally important. The contention is that the new coroners
service will be able to do that and that the new service will
be a point of contact with the relatives. I think that very many
relatives will still want to come to their doctor and be able
to discuss it. I find it so much easier to discuss with relatives
what exactly has happened if I know all the information. I sometimes
find myself in the position of saying that this or that may have
happened because I have not seen the post-mortem report and the
relatives say that, no, that did or did not happen because they
have been told it by the coroner's officer. It puts everybody
in a very difficult position.
Q187 Jessica Morden: I want to ask
about the appeals process in the draft Bill which makes provision
for the bereaved and others to appeal about anything at any stage
in the process. Do you think that this will work? What difficulties
can you see? What is your view on it generally?
Dr Wilks: In general, we believe
that proposals to improve the understanding and knowledge that
relatives have and their involvement in this very painful process
can only be a good thing. We have lived through the backlash of
Alder Hey and Bristol where, obviously, things were done by doctors
which were thought to be in everybody's best interests but turned
out to be perceived as extremely damaging simply because there
was not enough communication. That was a dreadful event that was
a very important learning process for the profession. We believe
that to think of it as an appeal tends in a sense to bring in
a rather confrontational element. While obviously an appeal process
is important, we hope that if the main provisions of the draft
Bill are designed to improve the involvement of families with
better communication—we have talked about the GP and the
coroner's officer—to help relatives understand exactly what
has happened and has been done it will reduce the level of antagonism
and misunderstanding that may take place so that appeals will
be less common. What would be more common would be good communication
and understanding. But at the end of the day if there is a serious
concern on the part of relatives that something has not been properly
investigated that appeal process should be in place. Part of the
concern about public engagement must come from a real fear that
another Shipman may be out there. What we say is that no reforms,
whether of the medical regulatory system in which Dame Janet Smith
has been engaged or the coroner and death certification and cremation
procedures, will reliably and conclusively stop another Shipman,
but what we can see in this draft Bill and other initiatives,
such as those relating to medical regulation, is the potential
for much better practice around a whole variety of different areas
of patient care—medical quality and proper death certification
and cremation certification—if our suggestions of a bit
more boldness are taken up. I do not think we should see all of
this as being focused on stopping another mass murderer. I think
that there are huge spin-offs for good medical practice and good
new processes coming out of this Bill as well as some of the changes
that have happened post-Shipman.
Chairman: Thank you very much indeed.
We are very grateful for your help.
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