Many death certificates give the wrong cause of death, because of the poor or even unacceptable quality of a quarter of all autopsies, an inquiry reveals today.
If families realised how sub-standard many autopsies were, there would be a furore, says the report from the national confidential inquiry into patient outcome and death.
"If one quarter of all surgical procedures undertaken on the living were deemed, by peers, to be poorly or unacceptably badly done, there would be a public outcry," says the report from the group, which operates under the umbrella of the National Patient Safety Agency.
"The fact that there is no outcry is a manifestation of the fact that families are unaware of the variable quality of the autopsy procedure."
The inquiry team reviewed 1,691 autopsies performed during a single week in May 2005. They found that in a third of mortuaries, the pathologist did not necessarily examine the body for any external injuries before it was opened up by a technician and organs removed. In one in seven cases, the brain was not examined.
In nearly one in five cases, the cause of death stated was questionable. The investigators were particularly concerned about deaths in seven specific areas: cardiac enlargement, cancer, infection, alcohol, possible suicide, deaths shortly after surgery, and epilepsy.
The team also found poor recording of external injuries and poor communication between coroners and pathologists - there were sometimes significant gaps in the information provided by the coroner to the pathologist. There was also evidence that very elderly people may not have been as carefully examined as younger ones.
When the variable quality of autopsies was raised with pathologists and coroners, some commented: "What do you expect for £87.70?" - the current standard fee.
Ian Martin, lead clinician with the inquiry, said people would be shocked by the report. "I think it tells us that the system needs looking at in detail and there needs to be a debate about what we need out of it. If the public is paying for a system, they should know what they are getting for their money."
The report into deaths in England, Wales, Northern Ireland, Guernsey, Jersey and the Isle of Man was timely, he said, because it would feed into the consultation over the draft coroners reform bill.
The investigation looked at autopsies ordered by a coroner when a death has been sudden or unexpected, which occurs in 22% of cases. These include cot deaths and the sudden deaths of young adults.
One of the crucial decisions that must be made, says the report, is the purpose of the autopsy: is it simply to rule out homicide, or is it to establish precisely the cause of death with the possibility that medical practice can learn from it? In some cases, rather than going to the lengths of examining every organ, the pathologist would settle for an acceptable cause of death, even if it was not the most accurate.
The Royal College of Pathologists, which suggested the inquiry, said better accountability and communication was needed. "The college does not condone 'cutting corners' in autopsy practice, but is aware of the pressures placed on many of its members by the current national shortage of suitably trained pathologists, and by other resource constraints," it said in a statement. "Many consultants now decline to undertake coronial cases, and those who continue often work under great pressure."
Epilepsy Bereaved is one of five charities lobbying politicians for a new national coroner service to replace the present locally funded system.
When a loved one dies, said Jane Hanna from the charity, "families are traumatised and put trust in the coroner to both respect the dead and look out for the living. This trust is currently misplaced because the whole service is neglected. Only a national service can address this."
