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The Autopsy in Deaths Under Fifty

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The Autopsy in Deaths Under Fifty The Autopsy in Deaths Under Fifty SIR CYRIL CLARKE, i<be, md, frcp, frs A.G.W. WHITFIELD, cbe, md, frcp The Medical Services Study Group of the Royal College of Physicians Dr James Clark, later Sir James Clark, physician to survey began, autopsy analysis was not one of the Queen Victoria, when visiting Fouquier at La Charite in objectives. In any case, if there is bias, it will almost Paris 160 years ago, was greatly impressed by the value of certainly be in the direction of minimising the true the autopsy in advancing knowledge and in teaching. The autopsy rate. Parisian example led to postmortem examination of the of majority patients dying in hospital in the UK, in other Results and Comments European countries and in America. During the past quarter of a century, however, the hospital autopsy rate Table 1 shows that, of the 1,000 patients, 471 had an has fallen[l,2] and differences of opinion about the value autopsy, 260 (26 per cent) as part of routine hospital of the procedure[3-15] have led the Royal College of practice and 211 (21.1 per cent) at the request of the Pathologists to set up an enquiry into the matter. This coroner, the Home Office or the Procurator-fiscal. The article sets out some information collected by the Medical autopsy rate of 47.1 per cent is much higher than the Services which was established the Study Group, by national rate (England about 27.3 per cent in 1975 and Royal College of Physicians in 1977, its terms of reference Scotland 23 per cent in 1974[ 1,2]) and this is thought to being to improve patient care in any way possible by be because all the 1,000 patients studied were under 50 means of medical audit. years of age. The higher autopsy rate in the Grampian Its first was an of deaths survey analysis under the age Health Board (67.3 per cent) compared with that in the of 50 in the medical wards of in occurring hospitals the West Midlands (50 per cent) and Mersey (40.9 per cent) West Midlands and Mersey Regions in England and the Regions is surprising, as the rate is known to be lower in Grampian Health Board in Scotland[16], Physicians in Scotland[17] because of the few postmortems asked for by all the hospitals were asked to lend the case notes of their the Procurator-fiscal. The probable explanation is that all patients who had died, between the ages of one and 50 the Grampian deaths took place in the teaching hospital years, during 1978 and 1979. In addition, they were while the comparable hospitals in the Mersey and West requested to send a personal confidential comment on the Midlands Regions made virtually no contribution to our case, where appropriate, and in many instances they were study, almost all their cases coming from the District kind enough to give supplementary information and General Hospitals. The higher rate in the West Midlands clarify doubtful issues. In a number of cases coroners also as compared with the Mersey Region is due to the greater supplied copies of relevant reports. The total number of number of coroners' autopsies in the West Midlands, case notes received was 1,290, and here are the first 1,000 probably reflecting different attitudes by coroners in the considered from the point of view of autopsies. For two Regions. various reasons[16] the ascertainment rate in our study Our study gave us the opportunity to assess the quality was only about 60 per cent, but we think that as regards of the autopsies. This was done by studying the reports, postmortems it is probably unbiased since when our their relevance to the clinical problem, the degree of co- Table 1. Autopsy rates and source in the three Regions. Total Total Autopsy case notes Total autopsy Hospital Coroner, etc Region scrutinised autopsies rate % No. % No. % Grampian Health Board 52 35 67.3 34 97.1 1 2.85 (pop. around | million) Mersey 413 169 40.9 102 60.3 67 39.6 (pop. around 2-j million) West Midlands 535 267 50.0 124 46.4 143 53.5 (pop. around 5 million) Total 1,000 471 47.1 260 55.2 211 44.7 152 Journal of the Royal College of Physicians of London Vol. 16 No. 3 July 1982 Table 2. Comparison of autopsies in two large District General Hospitals in England serving comparable industrial conurbations. Total Autopsy District General case notes Autopsy Hospital Coroner Hospital scrutinised Autopsies rate % No. % No. % A 99 66 66.7 7 10.6 59 89.3 B 98 56 57.1 36 64.3 20" 35.9 Coroner informed in another 4 but no autopsy requested operation by the physicians, the extent of the histology Table 3 shows a much lower autopsy rate in two West and the promptness with which the latter was carried out Midlands 'county town' District General Hospitals (C and reported. In the Grampian Health Board the stan- and D), serving large rural areas, compared with that in dard was thought to be uniformly very good, and in the the two District General Hospitals serving large industrial Mersey and West Midlands Regions it was good in some conurbations. Moreover, hospital D has a much lower autopsies and adequate in nearly all, but in a small rate than hospital C. The standard of autopsy in hospitals number of coroners' autopsies it was considered that the C and D was high and we did not think their lower rates standard should have been better. resulted from any lack of morbid anatomists. The main Table 2 gives the information on two District General factor appeared to be the physicians' attitudes to postmor- Hospitals, A and B, serving large industrial conurbations tems and their unwillingness, as well as that of their in the West Midlands. The differences are considerable, junior staff, to ask relatives for permission[18]. Further- especially in the proportion of cases in which the coroner more, they are less likely to have major teaching commit- felt it necessary to intervene. In England and Wales it is ments than those in hospitals A and B. well known that coroners' attitudes vary, many requiring Table 4 compares the clinical diagnosis with the autop- an autopsy in all the deaths reported to them, others in sy findings in the three Regions and categorises the cases as few as 55 per cent of deaths[17]. The coroners' requests into 4 groups: (a) in which (in our view) the clinical *n both hospitals contrast strikingly with the fact that in diagnosis was fully confirmed at autopsy and no other the Grampian Health Board only one of 35 autopsies was pathology was revealed (76.6 per cent of the total autop- carried out at the request of the Procurator-fiscal. The sies); (b) those where there were minor discrepancies Procurator-fiscal, however, has no obligation to establish between the clinical diagnosis and the autopsy or when the precise cause of death, but he must investigate any additional pathology was revealed but unrelated to the sudden, violent, suspicious or accidental death, or death cause of death (12.1 per cent); (c) those where there were from an unknown cause reported to him. Nevertheless, major discrepancies between the clinical diagnosis and usually, he requires an autopsy only when a crime has the autopsy findings (4.2 per cent); (d) where the clinical been committed or there is a possibility of death having cause of death was uncertain (7 per cent). Tables 5 and 6 been caused through negligence[17]. amplify categories (c) and (d). Table 3. Comparison of autopsies in two 'county town' District General Hospitals in England serving large rural areas. Total Autopsy District General case notes Autopsy Hospital Coroner Hospital scrutinised Autopsies rate % No. 9 No. 60 23 38.3 14 60.9 39.1 55 15 27.3 53.3 46.6 Table 4. Comparison between clinical diagnosis and autopsy findings in all three Regions. Percentage of Confirmation or discrepancy No. total autopsies (a) Clinical diagnosis fully confirmed and no significant additional 361 76.6 pathology demonstrated (b) Clinical diagnosis confirmed but minor discrepancies or additional 57 12.1 pathology revealed (c) Major discrepancies between clinical diagnosis and postmortem 20 4.2 findings (d) Uncertain clinical diagnoses, some of which were clarified by 33 7.0 autopsy (see Table 5) Total 471 99.9 Journal of the Royal College of Physicians of London Vol. 16 No. 3 July 1982 153 fc- ? (a) The fact that three-quarters of the patients were finding is the marked variability of autopsy rates, both correctly diagnosed clinically may be because the patients between and within Regions, and clearly there is no coroners and were relatively young and therefore likely to have been uniformity of opinion between clinicians, 'interesting cases' and also because confusing multiple pathologists on the role of the autopsy. Everyone has his pathology will have been present less often; lastly, the own views and we think it worth mentioning the biases of assessment was made by clinicians, not pathologists. two clinicians. In (b), of the 57 instances of minor discrepancies, the Pathologists tend to think that what they say is the last most common were the finding of symptomless gall- word, yet while this is obviously so quite often, the stones, the identification of a 'primary' in patients dying converse is not infrequently true, particularly with still- from carcinomatosis in which further investigation had births or neonates. Here, as we noted in our Rhesus been thought inappropriate, and acute pancreatitis[13], a deaths surveys[20,21], the actual cause of death was often not uncommon terminal phenomenon, particularly in unknown and 'the cause' was attributed to anatomical those dying from alcoholism.
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