Who dies at A&E? The role of forensic pathology in the audit of mortality in an emergency medicine department

Abstract

The authors reviewed a total of 481 deaths, which occurred in an accident and emergency (A&E) department of a major general hospital, over a 3-year-period, from 1 January, 1992 to 31 December, 1994. Of these, 428 (89.0%) were referred to the coroner, with full medico-legal autopsies being conducted in 236 (55.1%) of the latter. There was a marked preponderance of male subjects (male:female ratio = 1.86) and, not unexpectedly, the likelihood of an autopsy being performed decreased with the patient's age. Nevertheless, all patients who died from trauma (or unnatural causes) underwent autopsies, irrespective of age. In all, autopsies were conducted for 70 traumatic and 166 natural deaths, with the mean age (95% CI) of the former group being some 19 years less than that of the latter (33.2 (28.4–38.1) vs. 52.0 (48.6–55.4), P < 0.001). A comparison of the provisional causes of death (as recorded by the attending physicians in their clinical notes) with the autopsy findings yielded a higher diagnostic accuracy for traumatic deaths than for natural fatalities (correct diagnoses: 44 70 vs. 36 166 ; discordant diagnoses: 2 70 vs. 24 166 , P < 0.01 ). This difference was accentuated after the patients who were dead upon arrival were excluded ( 44 55 vs. 36 96 ; 2 55 vs. 24 96 , P < 0.005 ). As the injury severity score (ISS) is closely correlated with mortality, the autopsy findings were also used to calculate these values for 59 of a total of 70 patients who died from trauma or from unnatural causes. This showed that 24 had scores of 75 (incompatible with life), while 33 had ISS values above 16 (poor prognosis). The remaining 11 cases were not amenable to evaluation by means of the ISS.