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The Investigation of Events that followed the death of Cyril Mark Isaacs
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CHAPTER 37

Brain retention from post mortems after deaths in the Special Hospitals

Introduction

This chapter describes the procedures in place at the Special Hospitals following the 'Report of the Committee of Inquiry into Complaints About Ashworth Hospital', published in 1992. During this investigation my attention was drawn to this report as it contains a number of recommendations that are relevant to this investigation.
The report of the Committee of Inquiry was presented to Parliament in August 1992 and subsequently accepted by the Government.

Sources of information
The chapter is based on:

- the report of the Committee of Inquiry and the subsequent legal advice obtained by the Special Hospitals Service Authority (SHSA), and other guidance documents prepared by the Special Hospitals;

 

- the recollections of the Coroners, medical staff, pathologists, Coroner's Officers, morticians and other staff involved in the preparation for, and procedures during, post mortem examinations on the bodies of patients who have died while detained in the Special Hospitals.

The recommendations of the Committee of Inquiry
The following recommendations made by the Committee are relevant to the retention of brains for histological examination after post mortems carried out on the instructions of Coroners.
Recommendation 8
'We recommend that if a brain-damaged patient dies in a Special Hospital, the brain should be preserved for further examination'.
Recommendation 62
'We recommend that the Home Office should send a reminder to the Coroner's Society of the value of using Home Office pathologists in all suspicious deaths (and not simply those where there is a suspicion of homicide) which would include deaths in Special Hospitals'.
The Committee also commented that 'every death of a person in custody should be treated with suspicion, even if it rarely turns out that suspicion is justified'.
Basis of the Committee's recommendations
The Committee had heard evidence about the death and subsequent post mortem on a patient who was known to have pre-existing brain damage and who had died suddenly.
Dr Cocker, the Responsible Medical Officer (RMO) for this patient, had drawn the Committee's attention to the limitations of the post mortem examination. To Dr Cocker's surprise, the examination had not included any histological examination of the brain. Dr Cocker had expected the deceased's brain would be examined histologically, as the diagnostic findings could have been relevant to the cause of the patient's sudden death.
The Committee in their report state 'We commend the attitude of Dr Cocker, who told us that in future if a brain-damaged patient for whom he was the RMO, died in hospital, he would immediately contact the pathologist with a request to have the brain preserved for further examination'.
In making this recommendation the Committee had also heard evidence from Professor Michael Green, Professor of Forensic Pathology in the University of Sheffield. Professor Green had emphasised that when a post mortem was ordered following a death in an institution for the mentally disordered, the post mortem should be 'altogether more thorough, than if a death occurred in normal surroundings'.
Professor Green had emphasised that, whenever there was a history of previous head injury, the brain should be histologically examined after fixation. The Committee of Inquiry stated 'we endorse all that Professor Green states as a requirement for the proper post mortem examination of a patient who has died in a Special Hospital'.
It should be noted that the recommendation is intended to ensure a proper post mortem is carried out for diagnostic purposes in cases of previous head injury.
The Coroner's jurisdiction and procedures followed
All deaths in the Special Hospitals are reported to the Coroner, whether or not there are any suspicious circumstances, as all these patients are 'in custody'. This applies not only to patients who die in the Special Hospitals but also to those patients normally resident in the Special Hospitals but who die from natural causes in other hospitals to which they have been transferred for their medical care.
Specific procedures have been agreed with the Coroners of the three districts in which the Special Hospitals are located. These procedures require a full investigation to be made of all deaths, including those where the death was expected due to known and well-documented disease such as cancer.
To ensure that each death is fully investigated, the police and Coroner's Officers are routinely involved in the preparation of reports that are made available to the pathologist before the post mortem, in addition to the documents prepared by the staff of the Special Hospital concerned.
A Home Office pathologist appointed by the Coroner will carry out the post mortem examination. A Home Office circular requires that deaths in these institutions should be treated in the same way as if deaths were in prisons.
In addition to the Home Office pathologist and the mortician, the post mortem examination is attended by other official observers. While the persons in attendance vary between the three coronial districts, in each the police and/or Coroner's officer and other officials are present for the whole of the post mortem examination until the body is closed.
A very detailed post mortem report is available to the Coroner in every case.
An inquest in which the Coroner sits with a jury is held into all deaths in Special Hospitals.
The adoption of these procedures fulfils the recommendations made by the Committee of Inquiry.
Advice from the Special Hospitals Services Authority (SHSA)
Following the recommendation of the Committee of Inquiry, and having taken legal advice, the SHSA in March 1993 agreed to revised death procedures in the Special Hospitals.
This advice is significant as it emphasised that the approval of the next of kin should be obtained before the brain of a patient in a Special Hospital could be preserved for further examination, unless the examination was relevant to determining the cause of death. In doing so, the SHSA recognised the requirement for consent by the relatives that is an integral part of the Human Tissue Act.
What happened at each Special Hospital
I have investigated whether any brains were retained specifically as a result of this recommendation made by the Committee of Inquiry after their report was published in August 1992.
Ashworth Hospital
My enquiries show that there have been on average three deaths per year in the last six years with a maximum of six deaths in any one year. These figures include patients who were transferred for medical care to nearby NHS hospitals before their death. Almost all of these deaths were due to natural causes.
Coroners to whom deaths in Ashworth were reported
Mr Christopher Sumner succeeded Mr Gordon Glasgow as Coroner for the Sefton district of Liverpool in August 1998. Since that date, all deaths of Ashworth patients, including those who die in other Liverpool hospitals, have been reported to Mr Sumner.
Prior to August 1998, deaths in Ashworth Hospital itself were reported to Mr Glasgow, while deaths in NHS hospitals were reported to the Coroner responsible for the hospital in which the patient died.
All deaths have been followed by post mortem examinations at the Liverpool University Hospital (Aintree). The examinations have been carried by a Home Office pathologist appointed by the Coroner. Since 1996, most of the post mortem examinations on patients from Ashworth Hospital have been undertaken by Dr C P Johnson.
Policy at Ashworth
Following the advice of the SHSA in March 1993, Mr E A Jones, then the Director of Planning and Administration at Ashworth, issued a letter to all Responsible Medical Officers on 9 July 1993. This letter states:
'The purpose of this letter is to inform you of the legal advice the SHSA has received in relation to this (brain preservation), which is as follows:

1. If the patient has expressed the wish, then it is easier but unfortunately likely to be rare. The hospital would contact the patient's relative asking for written permission for the brain to be used for research purposes and the relatives confirm that there is no reason to believe that the wish was withdrawn later. The next of kin cannot prevent removal where the patient has authorised but need to be consulted as to whether the patient had changed his or her mind.

2. If the patient did not express a wish it is much harder (and also more likely to be the more usual case). The Hospital would contact the patient's relative asking for written permission and confirmation that neither of the following has happened:

a) The deceased actively expressed an objection to removal which was never withdrawn.

b) The surviving spouse or any surviving relative objects.

It should be noted that action needs to be taken within 4 days to be of any use.
It is usual after a special hospital death for there to be a Coroners Inquest and the Coroners consent for research is needed (though that is not expected to be a problem). The Coroners use of brain is confined to determining cause of death and so should return to the body when extracted for these purposes only.
The essence of the above advice is that the necessary checks have been made and authority has been received from the family in writing.'(1)
This policy was implemented at Ashworth from July 1993.
Officials attending post mortems on patients in Ashworth Hospital
The post mortem examinations on patients from Ashworth Hospital have, in addition to staff assisting the pathologist, been attended by the police who had investigated the death, the Coroner's Officer and a representative of Ashworth Hospital who had collated the documentation available to the pathologist. The latter was on most occasions Mrs Elizabeth Greenley, who has undertaken this responsibility since 1986.
Discussions with those involved in arranging or carrying out post mortems on patients from Ashworth Hospital
I have discussed the recommendation made by the Committee of Inquiry with:
Mr Sumner, Coroner for Sefton district;
Dr Di James, Medical Director of Mersey Health Care (which includes Ashworth Hospital);
Dr Johnson, Home Office pathologist;
Mrs Greenley, the member of Ashworth staff who collates the documents on each death;
Dr Cocker, whose observations led to the 1991 recommendation.
In addition, Dr James, on my behalf, has checked the documents of patients who have died in Ashworth Hospital.
None of those with whom I have spoken has any recollection of any brain being retained for diagnostic purposes from a post mortem examination on a patient in Ashworth Hospital since 1992, when the report was published. There had certainly been no occasion on which a brain has been retained for research.
Further reassurance that no brains had been retained is provided by the attendance at each post mortem of the police and other independent observers. Had brain retention occurred, this would have been observed and reported.

Broadmoor Hospital
All deaths in Broadmoor are reported to the East Berkshire Coroner and since 1991 had been followed by post mortem examinations at East Hampstead public mortuary until this mortuary closed in 1992. Since closure, post mortems have been carried out in NHS mortuaries. Where patients from Broadmoor died in nearby NHS hospitals, the post mortem examination was undertaken in the NHS hospital mortuary.
The number of deaths in Broadmoor was variable, but there had not been more than eight deaths in any recent year. Many of these deaths are from natural causes.
Coroners to whom deaths at Broadmoor were reported
Mr Peter Bedford has been Coroner for the East Berkshire district since 1998. Mr Bedford succeeded Mr Robert Wilson.
Mr Bedford had been unaware of the recommendation of the Committee of Inquiry and had no knowledge of any brain retention from patients who had died in Broadmoor Hospital, except where further examination was necessary for diagnostic purposes.
Following my letter to him, Mr Bedford had discussed the recommendation with his predecessor Mr Wilson, the pathologists who had carried out post mortems for him and for Mr Wilson, and with Mr Thomas, the Coroner's Officer with responsibility for investigating the deaths of patients who had died in Broadmoor Hospital.
Brain retention at Broadmoor Hospital
There are two separate aspects to the retention of brains of patients who have died in Broadmoor Hospital since 1991. These are separately described. The first relates to a research project in 1992 and 1993 under which four brains were collected, with consent of the relatives of the patient. This project had received Ethical Committee approval(2).
The second aspect is the development of the hospital policy in the light of the recommendation of the Committee of Inquiry(2).
Research project entitled 'Post-mortem Study of Special Hospital Patients'
The details of the project described below are set out in the Broadmoor Hospital archived records that were made available to me for the purpose of my Investigation(2).
In 1991 there were discussions between Dr Crow in the Division of Psychiatry at the Clinical Research Centre, Northwick Park, see Chapter 32, Dr Bruton at Runwell Hospital, see Chapter 34, and Dr Tidmarsh, Chairman of the Research Committee at Broadmoor Hospital.
These discussions led to the development of a research proposal for the study of brains of patients who die in the hospital. It was agreed at the outset that the study would require the consent of the patient's relatives.
In August 1991 the Coroner, Mr Robert Wilson, was approached. Dr Hemsted, the pathologist who undertook the post mortems, was also asked about the practical arrangements for the study if it proceeded.
In November 1991 the Broadmoor Ethics Committee considered the proposal. The Committee emphasised the importance of consent being obtained from the relatives of the deceased.
Further discussion of the proposal followed at the next meeting of the Committee in January 1992.
The project was formally approved at the meeting of the Ethics Committee held on 1 April 1992. This was before publication of the report of the Committee of Inquiry, see below.
The study was undertaken with the knowledge of the then Coroner, Mr Robert Wilson, who had agreed to the project on the basis that consent would be obtained from the relatives. The pathologist involved was the late Dr E H Hemsted.
It is clear from subsequent correspondence between Dr Tidmarsh, Director of Research, and the Coroner that few relatives were willing to give consent. By November 1993 after four brains had been collected, the project was discontinued.
On the information available to me it is clear that few relatives had been willing to consent to the retention of brains, which may explain why the project lasted less than 18 months.
It is also clear that the development of a new policy for Broadmoor Hospital, in the light of the recommendation of the Committee of Inquiry, had begun towards the end of the research project.
Development of a new hospital policy
Following the advice of the SHSA in March 1993, the hospital reviewed its policies. On 21 July 1994 Mr Alan Franey, the General Manager, circulated a new policy document entitled 'Hospital Policy on the Death of a Patient' to 'all Designated Hospital Policies/Procedures Manual Holders' at Broadmoor Hospital(2).
This policy in its opening paragraph states that 'the death of any patient in the Special Hospital must be reported to HM Coroner'. The policy continues to set out in detail many of the practical arrangements that should follow every death in Broadmoor Hospital.
A section headed 'Communication with Relatives' states:
'Consideration should be given to making a sensitive approach to relatives concerning the preservation of the brain, primarily in the case of brain-damaged patients'.
In a separate section on post mortems the policy states:
'Post Mortems
The RMO should contact the Pathologist before the post mortem takes place and advise, in particular, of any unusual circumstances …'
This part of the policy did not specifically refer to the retention of the patient's organs or brain.
Communication with relatives and the pathologist
However, detailed procedure sheets attached to the policy include the following:
'If appropriate, liaise with relatives and the Coroner's pathologist about neuropathological investigations'.
It is clear from these references that those responsible for the development of the policy had not only taken account of the advice of the Committee of the Inquiry and the SHSA but also recognised that brain retention for research unrelated to the cause of death was only lawful with the consent of the relatives.
1996 revision of the policy
The hospital's policy was next updated in 1996. The reference to 'preservation of the brain' was removed from the policy as staff who had been asked to discuss brain retention with relatives had become reluctant to do so and the practice had ended.
Pathologists
Three pathologists carried out post mortem examinations on patients from Broadmoor for Mr Bedford and Mr Wilson between 1991 and 2002. Dr Robert Chapman had carried out post mortems since 1994, the late Dr Hemsted, who retired in 1999, and Dr Fegan-Earle who had succeeded Dr Hemsted. Dr Hemsted was the pathologist involved in the research study already described.
Neither Dr Chapman nor Dr Fegan-Earle was aware of the recommendation of the Committee of Inquiry. Neither had retained brains from any patients who died in Broadmoor, except where further examination of the brain was relevant to the cause of death.
Coroner's Officer
Mr Brian Thomas has been Coroner's Officer since 1991. He has the responsibility for investigating all deaths of patients in Broadmoor Hospital. Mr Thomas has made it his practice to attend all post mortems on patients from Broadmoor Hospital. He has always remained in the mortuary until the post mortem is complete. In the context of the recommendation of the Committee of Inquiry, Mr Thomas has confirmed to me that to the best of his knowledge he does not recall any brains being retained after post mortem.
As Mr Brian Thomas has attended the post mortems on all patients who have died in Broadmoor Hospital since he became Coroner's Officer, he would have observed if brains had been retained in the circumstances recommended by the Committee of Inquiry.
Deaths in other hospitals of patients from Broadmoor
There have, however, been two occasions since 1991 when patients from Broadmoor died in other hospitals and the brains were retained for diagnostic reasons. Both died in nearby NHS hospitals where they were under care for medical conditions. In both cases, the papers available to me show that the pathologist considered that further examination and histology of the brain would contribute to determination of the cause of death.
The retention of the brain in these cases was for entirely proper purposes and agreed by Mr Wilson. On both occasions the relatives were aware that the brain had been retained. After histological examination, the brains were returned to the relatives of the deceased.
Summary of brain retention from patients who died at Broadmoor
There were two occasions when the brains of patients from Broadmoor Hospital were retained following post mortems carried out on the instructions of the Coroner. In both these cases histological examination of the brain was relevant to determining the cause of death. Both patients had died in nearby NHS hospitals to which they had been transferred for medical care.
Four brains were retained with the consent of the relatives for a research study undertaken in 1992 and 1993. This study had been approved by the Coroner and the Broadmoor Hospital Ethical Committee.
I am satisfied that, apart from these retentions which were authorised by the Coroner or with the consent of the relatives, no other brains were obtained from patients from Broadmoor Hospital.

Rampton Hospital
The SHSA's advice would have been available to the managers of Rampton Hospital, but no consequential policy statement has been made available to me and there is no recollection of any such policy being developed. There is no reference to the procedures recommended in the 1991 report in the current Rampton policy documents.
My enquiries confirm that all deaths of patients from Rampton are reported to the Nottinghamshire Coroner and that the post mortems are carried out by a Home Office pathologist at the mortuary at Bassetlaw Hospital. This mortuary serves as a public mortuary as well as providing mortuary services for the NHS.

The Coroners to whom deaths at Rampton Hospital were reported

Dr Nigel Chapman has been Coroner for the Nottinghamshire district since 1993. This district includes responsibility for Rampton Hospital. Dr Chapman's predecessor as Coroner was Mr Jenkin Jones. Dr Chapman was unaware of the recommendation prior to my enquiry.
The number of deaths in Rampton Hospital is similar to that at Ashworth. There have been between three and five deaths each year in recent years. The majority of deaths are due to natural causes.

Pathologists
Professor Rutty, Home Office pathologist, who is now based at Leicester University, has carried out the majority of post mortems on patients who have died in Rampton Hospital since 1996. Professor Rutty initially carried out these examinations when he worked in the Department of Forensic Pathology at Sheffield. He has continued to undertake the examinations at Dr Chapman's request since he took up his appointment at Leicester in 2001.
Professor Rutty was unaware of the recommendation of the Committee of Inquiry. However, he and his predecessors acting for Dr Chapman had retained brain tissue samples, but not whole brains, as a matter of routine during post mortems on patients from Rampton. This procedure follows Home Office advice when an inquest will follow.
Professor Rutty states that the only circumstance in which he would retain the brain would be for fixation prior to histological examination. In his experience, this was rarely necessary. He did not recall any occasion when a brain had been retained except for diagnostic reasons, which he had always reported to Dr Chapman.

Mortician at Bassetlaw Mortuary
At Dr Chapman's suggestion, I made further enquiries of the mortuary staff at Bassetlaw General Hospital. The post mortem examinations on patients who die in Rampton Hospital are attended by a number of officials. (This follows a similar pattern to attendance of officials at post mortems on patients who die in the other Special Hospitals.)
Mrs Patricia Dady is the senior technician at the Bassetlaw mortuary and has worked there since August 1993. Mrs Dady confirmed that the bodies of all patients who die in Rampton are transferred to the Bassetlaw mortuary where a post mortem examination is always undertaken by a Home Office pathologist.
Mrs Dady confirmed that the brain is examined in all post mortems undertaken by Home Office pathologists and tissue samples taken. The brains are returned to the body before closure.
Mrs Dady could remember only two occasions when the whole brain of a patient from Rampton Hospital had been retained at the end of the examination. On both occasions, retention had been for histological examination relevant to the cause of death. The retention of these brains had been reported to Dr Chapman. In one case, disposal of the body had been delayed so that the brain could be returned to the body.

Brain retention from patients at Rampton

I am satisfied, on the basis of the recollections of Professor Rutty, Mrs Dady, Dr Chapman and others who they have consulted, that brains have not been retained from patients in Rampton Hospital except when histological examination was required for diagnostic purposes and this was discussed with the families.

Summary
In 1991 the Committee of Inquiry into Complaints about Ashworth Hospital recommended that 'if a brain damaged patient dies in a Special Hospital, the