The coroner's autopsies in the Great Britain: the problems related to the quality of the studies, standardization, auditing, financial support and the approaches to their solution

Abstract

This article continues the series of previous publications of the authors based on the analysis of the detailed report of the experts of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD) designed to evaluate the quality of autopsies carried out by the coroners in the Great Britain. It was shown that only in 13 to 55% of the 1,691 case the operators had an opportunity to refer the necropsy materials for the pathological study. The problems encountered in association with histological and toxicological analysis arose from the misunderstanding between the coroners and the pathologists as regard the organizational aspects of autopsy studies as swell as the financial and economic considerations. The Coroner Rules that had been adopted in 1984 and remained in force in the country until 2005 needed to be radically revised, corrected, and amended to facilitate the solution of a number of problems and eliminate the formal organizational and technical contradictions that hampered the further improvement of the quality of autopsies that must be performed by the corners at the national rather than the local level. The maximum number of the unacceptable results were revealed in the protocols of autopsires carried out by the forensic medical experts. All pathologists in the Great Britain are recommended to pay special attention to all cases of sudden death of the adult subjects and the deceased epileptic patients. The detailed investigations are mandatory in all cases of death following medical manipulations, such as surgical interventions, and complications.