119.We heard that there is a serious shortage of pathologists available to carry out post-mortem examinations for coroners which leads to delays in releasing bodies and completing coroners’ investigations. Neither any central government department nor the NHS accepts responsibility for the supply of pathology services to the Coroner Service. Post-mortem examinations and reports prepared for coroners by pathologists are not covered by NHS contracts. Coronial pathologists are usually NHS consultants working privately outside their normal hours. Their services for coroners are provided for a fee.
120.The standard fees for pathologists’ services to the Coroner Service are set by the Lord Chancellor with the agreement of the Lord Chief Justice. André Rebello, Honorary Secretary of the Coroners’ Society of England and Wales, told us:
a pathologist is supposed to be able to do a standard post-mortem for £96.80 and £276.90 for a special examination. I do not know how many of you have recently employed a plumber, bricklayer or joiner, but £96.80 often reflects tens of hours of reading medical records, examining the body, preparing slides, looking down the microscope, deciding what to send off to toxicology and what other special examinations are needed.
121.The shortage of pathologists available to do work for coroners is long-standing and becoming more acute. Dr Mike Osborn, President of the Royal College of Pathologists, told us:
You will run out of pathologists to do post-mortems for you [ … ] there will be huge delays and problems because pathologists are not taking on post-mortems—it is not part of NHS work. There are already 580 consultant pathology vacancies in this country. There are not enough pathologists to do the diagnostic work in this country, and it has come down to the basic choice of [NHS] trusts supporting cancer diagnosis, inflammatory bowel disease or post-mortems, which is not part of their role.
The Coroners’ Society told us:
The service is essentially being propped up by older and experienced pathologists with fewer younger colleagues coming through the ranks to replace them. The impact on families is delayed investigations and delays in the bodies of their loved ones being released back to them for funerals to take place.
Neither the DHSC nor the MOJ will grasp this nettle. It must be grasped before there is no-one left who can train autopsy pathologist of the future.
122.Post mortem examinations generally include dissection of the body so that organs and tissues can be examined. The Chief Coroner, Judge Lucraft, told us about the sensitivities relating to post mortem examinations:
Coroners, with their support staff, try to do their very best to explain what the process is. There can be quite difficult conversations, occasionally, where a post-mortem may be required. Not only those with very strong faith concerns about the invasion of the body but most of us do not like the idea of a loved one being examined post death to see what has happened.
123.In more recent times and in some areas less-invasive post-mortem techniques (for example CT scanning) are available in appropriate cases as an alternative to dissection but may have to be paid for by the people who have been bereaved. The Coroners’ Society said: “Families in one area should be able to have a less invasive scan by way of post-mortem investigation as any other area, and without any cost.”
124.André Rebello, Honorary Secretary of the Coroners’ Society made the same point about fairness:
I object most strongly to families and communities being charged for coronial post-mortem investigations. If I order a post-mortem [by dissection], the relevant authority funds it. Relevant authorities do not fund less invasive autopsy, and it is not right that we have this unevenness within the service.
125.Dr Osborn told us more about scanning, and its limitations:
Minimally invasive autopsy is very good but it is not the magical answer to all the questions everybody wants it to be [ … ] in good centres with well-trained staff you can get the answer to the cause of death in up to 70% of cases. In some studies it is 90%, but realistically it is about 70% of cases.
126.The Chief Coroner, Judge Lucraft, said scanning was increasing and was welcomed by some faith groups:
That can assist many coroners with what might be termed ‘relatively straightforward post-mortem investigations’. I know that faith communities, in particular, welcome scanning, which means that there does not need to be a more invasive post mortem.
127.Dr Osborn told us coroners’ officers play an important role with respect to post mortem examination as how a post-mortem is done is based on information they provide:
In some areas they are furnished with scene photographs, police statements, statements from coroners’ officers and so forth. In other areas you get just two lines written on a piece of A4 saying, “Person found dead in Tesco”, or something like that. There is literally that much difference.
128.Giles Adey, from Kent County Council told us that investing in scanning now could save money later:
We are validating the numbers at the moment, but potentially we are looking at a capital investment of £3 million that would be repaid over a period of nine years, after which it would deliver significant annual revenue savings.
129.In his recent annual report, the Chief Coroner invited senior coroners and local authorities to consider providing “access to CT scanning facilities as a way (a) to take some pressure from conventional autopsy provision; and (b) to provide a robust form of post-mortem evidence capture including for disaster victim identification (DVI), mass fatality and other special cases.”
130.The Chief Coroner, in his recent annual report refers to the 2015 Hutton review of pathology in England and Wales where Professor Hutton described the immediate future of both forensic and non-forensic pathology services as “fragile, and corrective action needs to be taken now”. The Chief Coroner has repeatedly called for urgent action to support pathology services in his annual reports. For the longer term he supports Professor Hutton’s proposal that pathology services for coroners be organised regionally in 12 to 15 regional centres of excellence.
131.Dr Osborn agreed that a regional model would be the best way forward. We received evidence from individual coroners, such as Andrew Haigh, Senior Coroner for Staffordshire (South), about the shortage of pathologists and supporting the creation of regional centres.
132.Giles Adey from Kent County Council told us of the difficulties in improving pathology services from a local authority point of view:
The difficulty is that we have never come to a point where regional mortuary provision is at the top of the respective local authorities’ priorities [ … ] Regional provision would make absolute sense, but the question is how it would be funded. I think the challenge would be for Government in funding the capital or set-up costs, because of the difficulties of agreeing it locally, and then for local authorities in a region to collaborate and work together on the revenue consequences.”
133.Alex Chalk told us that the Ministry of Justice recognises that there is a shortage of pathologists to carry out work for coroners and is working with others to try and fix it:
I entirely accept that this is a pinch point and it is something that the Government are very much aware of, and we are working across Government to see what progress can be made.
136.In the medium term the Ministry of Justice should work with the Department of Health and Social Care so that pathologists’ work for coroners is planned for within pathologists’ contracts with NHS trusts.
137.In the longer term, the Ministry of Justice should broker an agreement between relevant government departments and the NHS (in England and Wales) for the establishment and co-funding of 12–15 regional pathology centres of excellence.
119 , November 2020, para 103
120 The Coroners Allowances, Fees and Expenses Regulations 2013 () para 6 of the Schedule
123 The Coroners’ Society of England and Wales (), section 1(e)
124 The Coroners’ Society of England and Wales (), section 7 of the executive summary
126 The Coroners’ Society of England and Wales (), section 7 of the executive summary
132 , November 2020, para 63
134 , November 2020, paras 104–106
136 Mr Andrew Haigh (), para 1