Abstract
The paper by Professor Pounder and colleagues 1 merits some response. The paper is a description of procedures followed for some years in one region of Scotland, with a modest population of 388,000. The paper makes no attempt to validate the procedure, so that the reader cannot know whether or not the Dundee initiative provides reliable causes of death. Indeed, the method used is not fully described in the paper, albeit it appears that one of the essential pre-requisites is a police investigation and the availability of medical records – neither of which is invariably available to the coroner in England or Wales when considering cases of sudden death with unknown cause.
The law in Scotland concerning death investigation differs markedly from the law in England and Wales, such that care is necessary before making assertions that if the Dundee initiative were to be applied to England and Wales, the autopsy rate would be reduced from 110,000 to 30,000 p.a. The paper gives the impression that the Coroners and Justice Act 2009 is now in force – but it is not. Although it received Royal Assent in November 2009, the part relevant to coroners has yet to be implemented and the coalition government elected in 2010 has already stated its intention to modify the Act in important ways. It remains to be seen whether or not the Act is implemented and if so in what form; but even if it is, the provisions regarding postmortem examinations contained in section 14 will not greatly alter current arrangements.
It is agreed by many (including coroners) that the autopsy rate in England and Wales, currently 22% of all deaths, is very high. It is important to find satisfactory means of reducing the numbers of coroner autopsies. However, the current law (and the law if the 2009 Act is implemented) does not alter the provisions of the Births and Deaths Registration Act and regulations. These require that every death in England and Wales must be registered. This may be done in one of two ways. A registered medical practitioner who was in attendance during the final illness of a deceased person may issue a Medical Certificate of Cause of Death (MCCD), stating the medical cause of death to the best of his/her knowledge and belief. In the absence of such a MCCD, the death can only be registered if a Coroner provides the necessary documents to enable registration to take place.
In the aftermath of the Shipman case and subsequent regulatory actions, registered medical practitioners are less willing than they were pre-Shipman to issue a MCCD if there is any doubt or uncertainty about the cause. Furthermore, government altered the terms of the General Practitioner (GP) contract to allow general medical practitioners to opt out of the provision of care out-of-hours. The consequence is that many patients die not having seen their GP during their final illness.
Additional difficulties arise when patients die not having seen their doctor for many weeks or months. In cases of sudden death where the cause is unknown, and there is no medical history of recent illness available, the death will inevitably be a matter for the coroner. The legislation then requires the coroner to hold an inquest – unless, making use of section 19 of the Coroners Act 1988, s/he can dispense with an inquest because the autopsy that s/he has requested yields a cause of death that is natural and the other circumstances are such that no inquest is necessary. There is little scope in the current legislation for the coroner to avoid the need to request an autopsy. S/he can try to persuade registered medical practitioners to issue, but this cannot make serious inroads into halving the numbers of autopsies so as to bring England and Wales into line with other Commonwealth and Western democracies.
One possible way forward is to make use of alternative diagnostic techniques, such as computerized tomography and/or magnetic resonance imaging. The Department of Health in England sponsored research into the reliability of imaging techniques and the initial results were presented at an RSM symposium (Imaging the Dead) on 21 October 2010. It appears clear that while imaging techniques have much to offer they are far from being a reliable method of establishing causes of death in a significant proportion of cases.
It would, of course, be helpful if the Dundee team or the relevant government body in Scotland were to undertake comparable research into the reliability of the ‘view and grant’ methods used in some regions of Scotland. It would also be of interest to know why the Glasgow region makes little use of the ‘view and grant’ method.
Whatever ‘moral issues’ arise, coroners, as law officers, must obey the law set out by the legislators. The moral, ethical and other issues were all debated at length over the past decade yet Parliament, in passing the 2009 Act, did not amend the requirement for accurate certification of medical causes of death. There is a need to try to find reliable methods of establishing medical causes of death other than by the conventional autopsy. Imaging techniques might provide an answer in some cases. Whether or not a Scottish ‘view and grant’ method can be regarded as a reliable alternative in England and Wales is something that requires scientifically valid research and not mere proselytisation.
Footnotes