In the name of Allāh, Most Gracious, Most Merciful

Digital Autopsy v Invasive Autopsy (Post-Mortem)

7. DIGITAL AUTOPSY v INVASIVE AUTOPSY (POST-MORTEM) 

  1. Post-mortem, also known as autopsy, is a detailed examination of a dead body to try to determine the medical cause of death.  A post-mortem examination will be carried out if requested by the coroner or a hospital doctor. If a post-mortem is requested by the coroner the next of kin are not asked to give consent (permission) for the post-mortem to be carried out. The coroner is a judicial officer responsible for investigating deaths in certain situations, deaths which are unexpected, violent, unnatural, suspicions, as a result of an accident or injury or occurred during an operation or soon after an operation. 
  2. The post-mortem is carried out as soon as possible, usually within two to three working days of a person’s death, sometimes even earlier, by specially trained doctors called pathologists. The post-mortem involves removing major organs from the dead body, such as the heart and lungs, on occasions it make be necessary to remove the brain as well, for examination to try to determine the cause of death.  
  3. In around 20% of adult post-mortem examinations and in most paediatric post-mortem examinations, the cause of death is not immediately obvious. A diagnosis can only be made by retaining small tissue samples of relevant organs for more detailed examination. Organs or tissue samples may need to be sent to specialised units for further analysis. When the post-mortem examination is complete, you will be told whether tissue samples and organs have been retained.  
  4. In cases where cause of death cannot be easily ascertained the post-mortem can take several weeks to complete. After a post-mortem, the organs are returned to the body, the pathologist writes a report of the findings. If the post-mortem was requested by the coroner, the coroner or coroner's officer will let you know the cause of death determined by the pathologist. 
  5. Digital autopsy or digital post-mortems are available which obviate the need to perform the traditional invasive post-mortem to try to determine the cause of death. Digital autopsy involves the body undergoing medical scanning (CT scan or MRI scan). The CT scan takes only minutes to perform. The digital data obtained form the CT scan is used to create a 3D image of the whole body. Using special software specially trained radiologists can examine the digital reconstruction of the dead body identify the cause of death in more than 70% of adult cases. The cause of death identified by the radiologist from the scan has to be accepted by the coroner’s pathologist before a medical certificate of cause of death (MCCD) can be issued. 
  6. In England and Wales for a digital autopsy to be carried out it has to be sanctioned by the coroner involved with the case. Unfortunately, some coroners do not “believe” in digital autopsies and insist on the traditional invasive post-mortem approach. A truly sad state of affair in this age of digital technology. This may be partly due to the fact that the vast majority of coroners are solicitors by training rather than doctors. In a High Court ruling in 2015, Mr Justice Mitting, stated that an invasive autopsy should be avoided so long as there was a “realistic possibility” that a non-invasive autopsy would establish cause of death. 
  7. If you wish your dead relative to have a digital autopsy rather than the traditional invasive autopsy (post-mortem) you need to make a request to your local coroner that you wish to have a digital autopsy. A digital autopsy will be performed if considered appropriate.
  8. Currently, the bereaved family must pay for the digital autopsy themselves, where as the local Council pays for the pathologist for traditional invasive post-mortem. The only exception to this is Sandwell Council which pays for its residents undergoing digital autopsy. 
  9. In cases where the digital autopsy cannot identify the cause of death then a traditional invasive post-mortem will be necessary, however, in some cases the digital autopsy will provide useful information to reduce the invasive post-mortem to a minimum.

Cooperation to provide a CT scan death investigation service

By ,   24 August 2018   Source

Dr James Adeley and Professor Mark Pugh recount how a local authority, NHS acute trust and private provider came together to provide a free at point of delivery digital autopsy post-mortem scanning service in Lancashire

CT scanner

The relationship between acute hospital trusts, the medical director and the coroner is always interesting, usually in more ways than one.

Although coroners in England and Wales are required to investigate deaths, the principal means by which they establish a cause of death is at a post-mortem performed by pathologists, who are employed by acute trusts.  

In 2016, it became apparent that with past and impending retirements, in late 2018 there would be a critical shortage of pathologists to undertake post-mortems across the three acute trusts in Lancashire.

Replacement by recruitment was likely to be difficult due to a decision by the Royal College of Pathologists over a decade ago to make the post-mortem training an optional requirement for histopathologists.

The lack of capability to undertake post-mortems left the coroner with the unenviable task of deciding which cases would have a post mortem and for the remainder to conduct short notice inquests requiring attendance at court/statements by treating hospital consultants to establish a cause of death. The latter option would have a significant impact on healthcare delivery to the living.

A traditional post-mortem involves opening of all of the body cavities and skull and the removal and examination of all the organs before reconstruction takes place.

 

Post-mortem CT scanning

In recent years, there has been research conducted into the use of post-mortem CT scanning to establish the cause of a deceased person’s death.

A 2017 research paper in the Lancet established the high correlation between PMCT and findings at an invasive post-mortem. A diagnostic rate of 92 per cent of those cases scanned was achieved by using ventilation of the lungs and injection of radio-opaque dye into the coronary arteries.

The paper concluded that in most cases either a traditional post-mortem or a PMCT was sufficient to establish a cause of death but that both had certain weaknesses

The paper concluded that in most cases either a traditional post-mortem or a PMCT was sufficient to establish a cause of death but that both traditional and PMCT post- mortems had weaknesses in certain areas. There are also a number of PMCT scanning protocols, each having a different time taken to undertake a scan and a different diagnostic success rate.

The limiting factor in Lancashire was the number of pathologists available and consequently the ventilation/dye injection protocol was selected as it potentially reduced the pathologist’s workload most significantly.

 

Lancashire PMCT pilot

A Lancashire PMCT pilot was commenced with a lead consultant radiologist being trained in the interpretation of post-mortem CT scanning. A specialist forensic radiographer was also trained and the pathologists helpfully cooperated undertaking the external examination of the bodies.

The cases selected for scan were those of unexpected death in the elderly. The scans were conducted outside normal working hours using an existing CT scanner and proved that nearly all PMCT cases would diagnose the condition causing death.  

As a result, it was concluded that an NHS based PMCT service was a viable possibility. Furthermore, as the cause of death was diagnosed with an imaging modality in which the radiologists were the specialists, a PMCT service could be provided with the radiologist giving the cause of death and without the need to add to the pathologists’ workload.

As the cause of death was diagnosed with an imaging modality in which the radiologists were the specialists, a PMCT service could be provided without adding to the pathologists’ workload

The external examinations are undertaken by anatomical pathology technicians who have received significant additional training by a Home Office pathologist in recognising abnormal forensic signs.

Although concerns have been raised about this approach, the APTs have identified four cases of potential homicide previously described as non-suspicious resulting in one person being charged with homicide and three ongoing homicide investigations.

 

Splitting of roles

Lancashire County Council, the relevant local authority responsible for resourcing the coroner, agreed to support a PMCT service as the principal investigation to establish a cause of death provided it was cost neutral as against the cost of traditional post mortems.  

Discussions between Lancashire Teaching Hospitals trust and the council established that neither had sufficient available capital to purchase a dedicated scanner.

The coroner, the trust and the council engaged a private contractor to provide the digital autopsy scanner and its building, hardware for storage of images and, as the scanner was to be located centrally within Lancashire, transport arrangements for the deceased from remote mortuaries.

The coroner, the trust and the council engaged a private contractor to provide the digital autopsy scanner and its building, hardware and transport arrangements for the deceased

However, provision of radiologists, forensic radiographers were to be provided by the trust and activities undertaken as part of their job plan.  

This splitting of the role reduced both commercial disadvantage in negotiations and risk of a lack of continuity of service were the commercial arrangements to cease. This was in accordance with the council’s commercial strategy of spending public funds locally wherever possible.

 

A non-invasive alternative

The result is a local authority, NHS acute trust and private provider successfully cooperating to deliver free at point of delivery digital autopsy post-mortem scanning to the majority of the population of Lancashire.  

This has been delivered at a less than cost or cost neutral expenditure when compared to traditional post-mortems. The PMCT service now has 14 consultant radiologists, specialist forensic radiographers and six trained APTs.

In the first three months of operation, over 90 per cent of scans established the cause of death avoiding 415 invasive post-mortems.

The comfort and benefit delivered to bereaved families by the knowledge that an accurate cause of death has been identified without resorting to evisceration of the body is considerable and not to be underestimated.

William Beveridge’s quote of NHS care “from the cradle to the grave” can now include PMCT in its care of deceased persons providing a non-invasive alternative for the investigation of death in large scale geographically dispersed populations.