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The Investigation of Events that followed the death of Cyril Mark Isaacs
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FOREWORD

This report was instigated by the events that took place following the untimely death of Mr Cyril Isaacs on 26 February 1987, and the post mortem examination that was carried out the following day at Prestwich Hospital mortuary on the instructions of the Coroner.  
 
The need for an investigation of these events followed the discovery by Mr Isaacs' widow, Mrs Elaine Isaacs, on 5 April 2000 that the brain of her late husband had been retained during the post mortem on the morning of 27 February 1987 and taken later that day to Manchester University for use in research.  
 
The retention of Mr Isaacs' brain and the intended use for research took place without the knowledge of Mr Isaacs' relatives. Had Mr Isaacs' family been aware at the time of the retention of any of Mr Isaacs' organs, this would have been vigorously opposed.  
 
Mrs Isaacs submitted a detailed statement for the Chief Medical Officer's Summit on Organ Retention held on 11 January 2001. On 30 January in a debate in the House of Commons on the issues raised at the Summit, Mr Ivan Lewis MP drew attention to Mrs Isaacs' discovery that Mr Isaacs' brain had been retained without the consent of the family.
Annex 1



Appendix 1
 
Following the debate in the House of Commons, Mrs Isaacs' son, Dr Austin Isaacs, wrote on 19 March on behalf of himself and Mrs Isaacs to Mr Alan Milburn, the Secretary of State for Health, requesting an investigation into what occurred following the death of Mr Isaacs.


Annex 2
 
The Chief Medical Officer, at the request of the Secretary of State, held a meeting on 4 May 2001 with Mrs Isaacs, Dr Austin Isaacs, and Mr Ivan Lewis. The meeting, which was also attended by officials of the Home Office and Department of Health, agreed that further investigation was needed to find out what had taken place following Mr Isaacs' death, and why.  
 
On 28 July I was appointed by the Secretary of State for Health, in my capacity as HM Inspector of Anatomy, to undertake the investigation of Mr Isaacs' death and, in particular, the retention and intended use for research of his brain.  
 
Terms of Reference
 
 
In October 2001, following consideration of the scope of the investigation, I was given the following Terms of Reference:  
 

'H.M. Inspector of Anatomy has been asked to carry out an independent investigation with the following Terms of Reference:

  

1.  To investigate and document the procedures and circumstances which led to the removal and retention of organs of the late Cyril Mark Isaacs during the autopsy performed at Prestwich Mortuary on 27 February 1987;

  

2.  To investigate what subsequently happened to the organs removed and retained;

  

3.  To review whether similar removals of organs occurred at other public mortuaries after deaths outside hospitals;

  

4.  To examine these events in the light of clinical and ethical policies, relevant legislation, religious beliefs, and the expectations and rights of relatives;

  

5.  To report conclusions and recommendations to the Secretary of State for Health.'

  
 
While the starting point of my investigation is the death of Mr Isaacs, my Terms of Reference were intentionally widely drawn. This was to require me also to investigate whether the circumstances of Mr Isaacs' death were unique, or whether similar retention of organs for use in research had taken place in other locations after post mortem examinations undertaken on the instructions of Coroners.  
 
Procedure and method of working  
 
While the Terms of Reference of my investigation were not formally announced, copies of these were made available to everyone who I have asked to assist me with this investigation, and to anyone else who enquired about the investigation, its scope and purposes.  
 
Throughout the investigation I was assisted by Mr Jim Connelly of the Department of Health. We undertook all discussions jointly, with the single exception of my first meeting with Mrs Isaacs and Dr Isaacs in August 2000. This meeting took place before Mr Connelly had been appointed.  
 
The first step in this investigation was to collate and read the considerable volume of papers that Mrs Elaine Isaacs had collected about the death of her husband. Thereafter the investigation was structured in four phases, which were sequentially:  
 
i. identification of what happened after Mr Isaacs' death;  
ii. investigation of organ retention for research at Manchester University;  
iii. documentation of post mortem brain research at other locations;  
iv. collation of the beliefs and views on the research use of retained organs from organisations representing religious, research and medical interests.  
 
To prepare for the first phase of the investigation, the papers collected by Mrs Isaacs identified the persons who were directly involved in the police investigation of Mr Isaacs' death, the post mortem examination at Prestwich mortuary and the research team at Manchester University which received Mr Isaacs' brain.  
 
In the first phase of the investigation, everyone identified during my initial review of records, letters and other documents were contacted by letter. An invitation was sent to everyone who could have relevant information to contribute to the investigation. The letters were modified to match each person's involvement in the events of February 1987. All those I wrote to were invited to tell me at a face to face meeting their recollection of events, procedures and practices that were in place at the time of Mr Isaacs' death sixteen years ago.
Annex 3
 
A similar methodology was used for later phases of the investigation. A summary record was prepared of every meeting or significant telephone conversation. Contemporaneous documents still available were obtained and copies made.  
 
After the initial review of paper work, the pattern of working from then on followed the course of an investigation rather than a formal inquiry.  
 
At this stage it is important to record that although no powers were available to me to compel anyone to respond, all those who were invited agreed to a meeting and/or provided access to relevant documents that were still in their possession. A full list of persons and organisations that responded to these requests or contributed to the investigation is at Annex 4.



Annex 4
 
Phase one  
 
During the first phase of the investigation its scope was broadened significantly for the following reasons:  
 

-  at a meeting at Manchester University in November 2001 the records of the brains received for research between 1985 and 1997 were provided. These records showed that large numbers of brains had been received from Coroners' post mortems undertaken in several different mortuaries in the Manchester area. As cases from Coroners' post mortems relevant to the investigation had been undertaken in hospital mortuaries as well as public mortuaries, and included some deaths of hospital inpatients, the categories of brain retention to be investigated were reviewed. It was decided that the investigation would include all deaths where brains had been retained for research except for those where the post mortem examination had been undertaken with the consent of the relatives following a death in hospital;

 
 
  

-  the geographical coverage of the investigation was widened after the records reviewed during the first phase indicated that research or teaching on brains obtained from Coroners' post mortems had taken place in many other locations in England;

 
 
  

-  a number of families who suspected that organs had been retained after Coroners' post mortems on their relatives in other locations contacted me.

 
 
Phases two and three  
 
In phases two and three of the investigation these many contacts were followed up with visits to the research teams and NHS Trusts in other coronial districts. These visits included discussions with the Coroners and the staff of mortuaries and pathology departments. The visits are listed in Annex 5.

Annex 5
 
To provide an overview of brain retention from Coroners' cases at locations that had not been identified from the above contacts, the Chief Medical Officer provided me with access to the returns received in response to the Survey of Retained Organs and Tissues that he had conducted in 2000. A questionnaire was sent to those NHS Trusts that I had not already visited to discover what policies and consent procedures they had operated in the late 1980s and early 1990s.  
 
Phase four  
In the context of my fourth Terms of Reference, contact was made with representatives of religious faiths to explore the acceptability or prohibition on post mortems and organ retention to those of different faiths. It should be noted that objections to these procedures are not confined to those who hold religious beliefs.  


Validation of factual matters

  
 
To ensure the factual accuracy of this report, references to persons identified in it were shown, in draft, to the person concerned, except for those believed to be still alive, whose present whereabouts I could not discover. Where corrections of fact were required in the light of the comments received, these have been incorporated.  

Structure of the Report

  
The report is structured so that each chapter describes a different aspect of post mortems or organ retention. I must emphasise that the Summary, Main Conclusions and Unanswered Questions sections of the report should not be read in isolation but in the context of the relevant sections of the report as a whole.

There is inevitably overlap between chapters as each was intended to be self-contained. The first four chapters describe what happened to Mr Isaacs.

As organ retention after Coroners' post mortems proved to be much more extensive than envisaged when I was asked to undertake this work, I have concentrated on the retention of brains for research. The Chief Medical Officer's survey had shown that brains comprised almost half of all retained organs. In the time available I have not investigated the scope of other organ retention.

The joint programme

Much of the report addresses the research programme jointly arranged and undertaken by staff of the Departments of Psychiatry and Physiology of Manchester University. For ease of reference, and to distinguish this programme from other contemporary research in Manchester, this is referred to as the 'joint programme'.

Main findings
These will be found in the chapter on 'Conclusions' but there are many subsidiary findings in the summaries at the end of each chapter. These, while of lesser significance, deserve attention in their own right.


Documents referred to in the report

The correspondence and other relevant documents are included in separate volumes of annexes and appendices. The short documents are listed as annexes, while larger documents, including relevant statutes, are separately listed as appendices.


Acknowledgements

Responsibility for the content of the report, its conclusions and recommendations are entirely mine. In its preparation I wish to acknowledge the support and assistance I have had throughout the Investigation from Mr Jim Connelly, whose experience of investigative undertakings has been indispensable. I also wish to express my thanks to Miss Lesley Knight, Mrs Judith Peachey and Miss Patricia Browne, whose help with the preparation of the report has been invaluable. Many of the events I needed to investigate took place between 10 and 20 years ago and entailed the recovery of archived documents and papers.

I wish to record my particular thanks to Mrs Diane Turnbull, Clinical Governance Manager, Mental Health Services of Manchester; Mr Stanley Wilson, Pathology Services Manager at North Manchester General Hospital; and Mr Colin Carr, Pathology Manager at Addenbrooke's Hospital, for their assistance in retrieval of documents and arranging for me to see others who could provide relevant information.
Dr Jeremy S Metters CB
HM Inspector of Anatomy


 
       
 

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