Evidence submitted by The Oak Tree Surgery
I am writing on behalf of the partners at Oak
Tree Surgery. Since 2003, we have been trying to obtain copies
of post mortems carried out on our patients but have come up against
a brick wall when dealing with [our local coroner].
Doctors report deaths to the coroner if the
cause of death is unknown or if the deceased was not seen by the
certifying doctor, either after death or within fourteen days
prior to death or if there is anything violent, unnatural or suspicious
about the death. Death may also be reported if due to an accident,
self-neglect, industrial disease or related to the deceased's
employment, in cases of abortion, during an operation or prior
to recovery from the effects of an anaesthetic, suicide or during
or shortly after detention in police or prison custody.
The main reason we as GPs refer deaths to coroners
is where the death is sudden, unexpected or we are not in a position
to certify what the cause of death is. If we do not subsequently
receive a report from the coroner telling us what the cause of
death was, then we cannot learn from the experience and we are
not in a position to discuss the cause of death with the deceased's
relatives.
I have written to [the local coroner] on at
least three occasions and have not received a single written reply.
He did, however, speak to me on the telephone on one occasion
and was very pleasant but although he told me that he had no objection
to doctors receiving post mortem reports for patients for whom
they had been responsible during life, he did not subsequently
instruct his pathologists to send copies to the doctors and we
have been unable to obtain any post mortem results.
Due to the lack of progress, I wrote to the
Home Office and also involved [the Chairman of the Local Medical
Committee]. [He], like myself, received no reply to any of his
letters.
I know that other General Medical Practitioners
in [the area] feel like ourselves about this issue and I am also
aware that local hospital consultants are also unable to obtain
post mortem results on their patients.
We believe this is a significant clinical governance
issue as we cannot find out if we are making the correct diagnosis
on patients who die unexpectedly and are therefore not in a position
to learn from any errors or oversights we may have made.
It is our belief that a post mortem result is
an important part of a patient's clinical records and must be
sent as a matter of routine to the patient's registered General
Medical Practitioner and also to any hospital consultant involved
in their care. Apparently coroners are currently a law unto themselves
and there is no legislation to make them act in a standard manner.
We strongly feel that there is a need for legislation to correct
this deficit and help us as doctors provide the best possible
care to our patients.
Dr S K Madelin MB BCh
On behalf of the partners of Oak Tree Surgery
February 2006
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