Page last updated at 08:11 GMT, Wednesday, 20 January 2010

How real-life 'silent witnesses' save lives

Professor Lucas
VIEWPOINT
Professor Sebastian Lucas
King's College London School of Medicine

still from Silent Witness

The actors on Silent Witness may be performing autopsies one after the other but real-life pathologists seem to be suffering from a dearth of bodies.

In this week's Scrubbing Up, top pathologist Professor Sebastian Lucas says his profession has to get the message across more clearly that autopsies can save lives.

This is a plea to restore a bedrock of medical practice, education and research - the regular consented autopsy examination of dying patients, done by pathologists in hospitals.

Until the 1960s, it was standard practice for a large proportion of all people who died in hospitals to be autopsied, to find out more about their diseases, teach staff and students, and disseminate the knowledge into better clinical practice.

This consented autopsy is the type that used to be the most frequent - and the most useful - for advancing medicine

New epidemics such as HIV, variant CJD, and now, swine flu, can be elucidated through intensive study of the dead - not to mention the rising appreciation of inherited diseases which may only be evaluated through autopsy.

But now, less that 5% of all deaths in hospitals, and very few deaths at home, are examined through a consented autopsy.

Unnatural death

Autopsies come in two ways in the UK.

Either a coroner (procurator fiscal in Scotland) requests an autopsy when there may be an unnatural cause of death.

Clinicians seem to have lost interest in consented autopsies, partly through a belief that improved imaging (radiology) and results from biopsies and other tissue analysis solve all pre-death diagnostic dilemmas

Or a death certificate is completed and a doctor requests the relatives for consent to an autopsy examination.

This consented autopsy is the type that used to be the most frequent - and the most useful - for advancing medicine.

Instead, at 95% of all autopsies performed, the coronial autopsy now dominates - 108,360 done in England & Wales in 2008 (Britain's best kept medical secret).

However, these medico-legal autopsies are not intended to fully investigate deaths, but to determine whether there may be an unnatural component to them; and if it turns out not to be an unnatural cause of death, then there is no incentive (or legal need) to pursue the issues any further.

'Lost interest'

Clinicians seem to have lost interest in consented autopsies, partly through a belief that improved imaging (radiology) and results from biopsies and other tissue analysis solve all pre-death diagnostic dilemmas.

All pathologists agree that the impact of the HTA in the area of autopsy and public health has been negative - in part because of the now-protracted process of gaining consent, so most clinicians do not want to engage with it

However, the message from comparisons of causes of death derived from autopsies versus clinical diagnosis, and these have been done since Osler's time in the early 20th century, is that the serious error rate ('discrepancy' is a nicer term) has not changed: it remains around 25-30% in all countries with advanced health services.

Why? Medicine is difficult, and the input of modern investigative techniques is countered by the increasingly complex range of diseases and treatments that we face now.

With this imbalance in autopsy practice, medicine is not being well served.

Is this what the country wants?

I hope not, because thoroughly performed autopsies, with feed-back to the clinicians who managed the patient in life, continue to have a positive impact on medical practice, audit and improvements in care.

Consent forms

At the recent NCEPOD report launch (5th Nov 2009), the question was put to the audience of doctors: Can we rectify the impending disappearance of the consented autopsy?

Our masters in Westminster probably did not intend further to minimize the consented autopsy and its useful outcomes, but that is what happened


One specific answer came back: make the consent forms easier to fill in.

Why are they now so long, cumbersome and bureaucratic?

Because of the Human Tissue Act 2004 and the input of the Human Tissue Authority (HTA).

Most pathologists believe that the impact of the HTA in the area of autopsy and public health has been negative - in part because of the now-protracted process of gaining consent, so most clinicians do not want to engage with it.

Why are the forms so awkward?

Ultimately because of Alder Hey and Bristol, and the ensuing public backlash against pathology.

'Unintended consequences'

This is an example of the law of unintended consequences.

Our masters in Westminster probably did not intend further to minimize the consented autopsy and its useful outcomes, but that is what happened.

Whilst trying harder to convince more of our clinical colleagues about the utility of the autopsy, the ground has been cut from under us.

Can we get public support for a rethink within government on enabling an easier consenting process, whilst retaining the trust of the public?

The first need is to re-educate clinicians that autopsies will help them.

The second is to engage more with the public, informing them what they are missing through the autopsy opportunity; and to encourage the people who come back to pathologists, with thanks for investigating and explaining a death, to speak out openly.




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