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CHAPTER 42

Introduction

One consistent feature of the many post mortem reports reviewed during this investigation has been the almost total absence of any record that a brain had been retained. This finding was consistent at all the locations where post mortem reports were available. Only a handful of reports mentioned brain retention, even when this had been for diagnosis.
This chapter describes why many pathologists, in their reports to Coroners, did not mention that the brain had been retained. It also records the views of morticians. The chapter is based on:
-  findings made during this investigation;
-  observations of pathologists, morticians and Coroners in many locations;
-  guidance issued by the Royal College of Pathologists.
These sources identify a number of reasons that explain why brain retention was so rarely referred to in post mortem reports.
References to brain retention found in post mortem reports
Reports from the Manchester area
More than 120 post mortem reports from the Manchester area were reviewed during this investigation. These were all written between 1985 and 1995. In only two was brain retention mentioned. This finding surprised two pathologists at NMGH who had written some of the reports of post mortems at that mortuary. Their recollection was that they had usually referred to brain retention in their reports to the Coroner. The reports reviewed show otherwise.
Two pathologists at other hospitals agreed that they had not mentioned brain retention to the Coroner when the reason for retention was for research. In these cases, brain retention had no bearing on the cause of death. In the late 1980s organ retention was not a subject discussed among pathologists. The pathologists added that organ retention was so frequent at that time that no significance should be drawn from this omission.
Reports in other locations
Pathologists in other locations confirmed that they had not included organ retention in reports to the Coroner. Two Coroners who had later discovered this practice confirmed this. The pathologists all agreed there was nothing out of the ordinary about practice in Manchester. Practice there was no different from other parts of the country. Other Coroners reported that they had not known about brain retention and had expected the post mortem report to state whenever the brain, or other organ, was retained.
Why was brain, organ and tissue retention not mentioned by pathologists?
Various reasons were offered to explain why retention was so infrequently mentioned in reports to Coroners.
Avoidance of distress to relatives
The most common explanation offered was that pathologists did not wish to add to the distress of the relatives when this could be avoided. In some places it was reported to me that local understandings had developed with the Coroner so that the pathologist would allude to organ or tissue retention by including in the report 'histology will follow' or 'the results of more detailed investigations may become available', or words to similar effect. This would alert the Coroner that tissue, or an organ, had been retained and that further information from histological examination might become available later.
More than one pathologist reported that they had been told that 'colleagues' had been given instructions by the Coroner not to include the retention of organs in post mortem reports. Two Coroners referred to this practice although they had not themselves given any such instructions. These recollections are 'hearsay evidence' but in view of the consistency from unconnected sources they are included in this report. There is nothing in writing to confirm instructions of this kind were given by any Coroner.
Organ and tissue retention was not an issue among pathologists in the 1980s
Pathologists in Manchester and in other parts of the country were asked if organ retention was discussed by the specialty in the late 1980s. All replied that at that time organ and tissue retention was so much part of the post mortem room scene that it was not the subject of discussion within the specialty. Organ and tissue retention for research and teaching went unremarked and unquestioned.
The national collection of pituitaries
All pathologists and morticians were well aware of the national pituitary collection system, Chapter 5. Circular HC(77)29 issued by the Department of Health in 1977 was specifically intended to encourage removal of the pituitary glands when consent for a post mortem had been given by the relatives.
Pathologists remembered that the pituitary collection programme began as a research project. Pituitary collection had never been mentioned in post mortem reports. This had become part of post mortem routine. The fee paid for each pituitary added to the misunderstanding.
If it was acceptable to collect pituitaries for research but not mention this in post mortem reports, what was different about retaining brains for the same purpose?
Reasons why organ retention was regarded as 'normal' during post mortems
Further reasons were advanced to explain why organ and tissue retention was considered a normal part of any post mortem.
Professional training in histopathology
Professor Lucas, during a meeting at the College of Pathologists, explained that post mortem procedures were learned by trainees observing how senior histopathologists undertook the examination. This was, in effect, training by apprenticeship. In the 1960s and 1970s senior members of the specialty had frequently retained organs and other specimens that 'were of interest' for both teaching and research. Histopathologists in training had followed the practice of their seniors.
Organ retention was in the public interest and intended to improve knowledge and future patient care
In retaining organs and tissues primarily for diagnosis, pathologists had also been motivated by the public benefit that would result from histological or other examination of retained material for research and teaching purposes. The additional information gained would not only confirm diagnosis, but also enhance knowledge and thereby improve future health care.
In retaining organs for research, pathologists had intended to benefit patient care and serve the public interest by improving diagnostic accuracy. There were many research studies that could only be carried out on the organs of the dead.
Consent had been properly given for organ retention
Hospital post mortems
It was widely believed that the post mortem consent form signed by the relatives also indicated their agreement to the retention of organs and tissues. In the 1980s few consent forms made any specific reference to organ or tissue retention. A few forms asked a separate question about retention but most did not. In reality, many relatives did not realise that when they were asked to sign the post mortem consent form this would be regarded as consent for retention. Many relatives did not want to know any such details.
Coroners' post mortems
In the 1980s many pathologists believed that in a Coroner's case the consent of the relatives was not necessary for research. The Coroner had control of the body and could agree to organ retention. Whether the Coroner was in fact asked is a matter that has already been discussed.
In the 1980s, few NHS pathologists were aware that the Coroner could only consent to retention of organs that had a bearing on the cause of death, or as allowed in Coroners Rules 9 and 12, Chapter 5.
One pathologist wrote to me:
'For their part the pathologists believed that once a brain was retained for diagnosis it could be held after diagnosis was complete without informing the Coroner or the relatives. This belief was based on the fact that the brain had been originally held under the authority of the Coroner and was a belief reinforced in the training of the pathologists supported by precedence and established practice in other centres'.
None of the pathologists seen during the investigation recalled that they had seen or been told about the Home Office 1989 letter which reminded Coroners that organs and tissues could only be retained with the agreement of the relatives.
The policy of carrying out a 'full post mortem'
In the 1980s no distinction was made between hospital and Coroners' cases. Almost all would have been 'full post mortems'. Very few pathologists modified the post mortem procedure in a Coroner's case unless the Coroner had given specific instructions. This happened in some places, generally for reasons related to the religious beliefs of the deceased.
In pathology departments where a full post mortem was routine, samples of the brain would often be retained for histology. Everyone involved 'knew'. This applied both to hospital and Coroners' post mortems.
Pituitary collection had served to encourage the practice of a 'full post mortem' as the brain had to be removed before the pituitary gland could be collected.
When brain retention was mentioned, why was this not noticed?
Although pathologists provided the Coroners with the cause of death before an inquest was resumed, the written post mortem report was by no means always available in time for the inquest. Due to the number of post mortem reports arriving after inquests, Coroners relied on their staff to bring to their attention any unexpected or unusual features that had not been reported in time for the inquest.
When a post mortem report did include a reference to brain retention (or to some other organ), it was not surprising that such rare references were not always noticed. When histology reports arrived weeks or in some cases months after the inquest, these were frequently simply filed.
Pathologists did not believe organ retention was in any way wrong
It is important to record that pathologists who retained organs and tissues did not consider the practice was wrong. This point was emphasised by Professor Lucas during the meeting at the Royal College of Pathologists:
'Pathologists did not consider they were doing anything controversial or wrong'.
In the light of the comments made to me by other pathologists, it is clear that Professor Lucas' remark is an accurate reflection of what pathologists believed at that time. His observations were reinforced by many pathologists during this investigation.
Pathologists have been shocked and dismayed by the hostility the specialty has experienced since organ retention came to wide public notice. I am sure that pathologists genuinely believed that organ and tissue retention for research and teaching was in the public interest and would in due time result in better care for future generations.
Reservations of morticians about organ retention
Different views were held among the morticians. Some had no concerns about retention of organs in the late 1980s for the same reasons as pathologists. Other morticians had reservations about the scale of retentions in certain mortuaries, and the fact that the relatives were not told that organs had been removed.
One mortician in the Manchester area has, since 1990, kept a file with copies of all the consent forms for organ retention signed by relatives. He had noted and been concerned that the brain was the only organ for which the relatives were never asked to give consent.
Another mortician's reservations started when relatives viewing bodies after the post mortem asked about features on the body that had changed since the relatives had last seen the deceased shortly after death. The mortician knew the features in question were the result of organ retention or tissue removal about which the relatives had not been told. In one mortuary, the relatives had questioned why the ears of the deceased looked 'wrong'. The reason, the mortician knew, was that the temporal bones had been removed for surgical training purposes.
When this mortician's reservations increased at the scale of retentions, he spoke to the Coroner knowing that in doing so an argument with the pathologists would follow. The Coroner put a stop to retentions from his cases but retentions from hospital post mortems continued.
In another location, a mortician became concerned when a femur was removed for research and replaced by part of a broom handle.
Summary
Historically, in the training of pathologists, organ and tissue retention was seen as an important part of the routine. There was nothing exceptional or unacceptable in keeping for histological study any organ or tissue that was of interest.
The national pituitary collection programme, encouraged by NHS Circular HS(77)28, misled pathologists and morticians to believe that removal of organs and tissues was permitted when the relatives had already consented to a post mortem. This policy inevitably led to a full post mortem so that the pituitary could be harvested.
The policy of a full post mortem did not distinguish between hospital and Coroners' post mortems. This would include examination of the brain and retention for fixation in appropriate cases.
Some Coroners left the decision to retain organs and tissues to the discretion of the pathologists.
Some Coroners discouraged specific references to organ retention in post mortem reports. Others preferred an oblique reference such as 'histology may be available later'.
The retention of organs and tissues was considered to be 'in the public interest', but not a matter for routine inclusion in the post mortem report.
Organ and tissue retention were simply not an issue for pathologists in the late 1980s and early 1990s.
Some morticians were disturbed by the extent of organ retention, particularly when the results became noticeable to the relatives when viewing a body after post mortem.
A few morticians took these concerns to Coroners in the early 1990s. Where this happened the Coroners gave instructions that organ retention for research must stop. As morticians and pathologists work closely together, other morticians were reluctant to say anything to Coroners that would jeopardise their working relationships.

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