Saving Mothers' Lives: - Public Health Agency for Northern Ireland

184
15 Pathology
Harry Millward Sadler
Pathology: Specifi c recommendations
Autopsies should be performed to the standards identifi ed in the 2005 Royal College of Pathologists’
Guidelines 1 : the fundamental principle of which states that underlying everything is the need to
satisfactorily answer the issues presented by a death.
In all maternal deaths histology should be taken unless there are positive reasons against such an action.
Known reasons for failure to meet these standards should be stated in the clinicopathological summary.
Introduction
In this triennium, 2003-05, the pathology assessor reviewed 353 case report forms. Virtually all of
the report forms for the Direct and Indirect deaths were assessed: 120 out of 132 and 161out of 163
respectively. The remaining assessed deaths were from Coincidental or Late causes.
For 102 of the 353 deaths there was either no postmortem, or the postmortem report was not available
or not released by the coroner. Some of these were documented biopsy-confi rmed cases of progressive
malignancy where an autopsy would not have added value, in others the reports could not be released as
the deaths were sub judice. In a few cases the coroner refused to release the autopsy report. However, in
at least 17 of the assessed cases there were clinical issues that should have been addressed by a properly
conducted autopsy.
The quality of the autopsy reports
As in previous Reports, the quality of the autopsy reports fall into fi ve categories: excellent, good,
adequate, poor and appalling and these groups are used again here. It must be commented that although
some reports are categorised as poor because they did not suffi ciently address pertinent clinical issues
or differential diagnoses, they were adequate for the purposes of a coronial autopsy as they identifi ed the
ultimate cause of death. The numbers of reports in each category are shown in Table 15.1.
Table 15.1
Quality of autopsy reports assessed; United Kingdom: 2003-05.
Excellent Good Adequate Poor Appalling Total
n (%) n(%) n(%) n(%) n(%) n(%)
Direct 28 (27) 27 (26) 25 (24) 19 (18) 3 (3) 103 (100)
Indirect 21 (18) 46 (40) 19 (17) 25 (22) 4 (3) 115 (100)
Coincidental 4 (12) 10 (30) 13 (39) 6 (18) 0 (0) 33 (100)
Total 53 (21) 83 (33) 57 (23) 50 (20) 7 (3) 251 (100)
Whilst it is gratifying that the proportion of “excellent” and “good” autopsy reports is increasing, it is still
disappointing that there were seven appalling reports. Although the number was higher than in the previous
triennium, because the overall numbers had risen, the proportion remained similar, as Table 15.2 shows.