| There
are
important
differences
between
the
purposes
of
Coroners'
and
hospital
post
mortem
examinations.
The
majority
of
Coroners'
post
mortems
are
carried
out
to
identify
the
cause
of
death,
while
hospital
post
mortems
are
intended
to
investigate
the
extent
of
disease(s)
and
to
confirm
(or
revise)
the
cause
of
death
that
is
already
known.
These
different
purposes
indicate
that
the
scope
of
a
Coroner's
post
mortem
can,
and
indeed
should,
be
different
from
a
hospital
post
mortem,
particularly
when
the
procedure
is
undertaken
against
the
wishes
of
the
relatives
and/or
the
deceased.
|
|
|
|
| This
investigation
has
shown
that
the
different
purposes
of
Coroners'
post
mortems
have
been
overlooked.
The
practice
of
a
single
standard
post
mortem
has
blurred
the
differences
in
many
places.
|
|
|
|
| This
chapter
describes
these
differences,
and
why
they
should
influence
the
extent
of
Coroners'
post
mortems.
Subsequent
chapters
address
the
attitudes
of
professional
organisations,
the
public
and
religious
faith
groups
to
Coroners'
post
mortems
where
the
requirements
of
the
law
properly
take
precedence
over
the
objections
of
the
relatives.
|
|
|
|
Historical
perspective
|
|
|
|
| The
first
examinations
of
human
bodies
after
death
were
undertaken
centuries
ago
and
were
for
what
would
now
be
regarded
as
'research'.
The
reason
for
examining
bodies
was
to
identify
the
internal
structures,
their
relationships
and
functions.
While
the
position
of
the
major
organs
was
known,
many
of
their
functions
were
not;
for
example,
William
Harvey
in
1628
discovered
that
blood
was
circulated
round
the
body
by
the
heart.
|
|
|
|
| Later,
when
the
anatomy
of
the
internal
organs
was
known,
dissections
were
undertaken
for
medical
teaching
purposes.
|
|
|
|
| Investigation
into
the
cause
of
death
|
|
|
|
| The
office
of
Coroner
dates
from
the
Middle
Ages,
when
the
role
of
the
Coroner
was
to
find
out
why
a
person
had
died.
The
post
mortem
examination
was
introduced
much
later
as
a
better
way
of
identifying
the
cause
of
sudden
or
unexplained
death.
|
|
|
|
| The
Human
Tissue
Act,
1961 |
|
|
|
| Before
1961,
in
some
hospital
deaths
relatives
had
little
choice
about
whether
or
not
a
post
mortem
examination
was
carried
out.
There
were
always
some
relatives
who
objected
to
post
mortems
for
religious
or
other
reasons.
|
|
|
|
| The
Human
Tissue
Act
regularised
the
legal
position.
Since
that
date,
the
consent
of
relatives
has
been
required
for
all
hospital
post
mortems.
(When
a
death
occurs
in
hospital
and
the
deceased
has
no
known
relatives,
this
responsibility
falls
to
the
hospital
authorities.)
The
relatives
can
also
place
limits
on
the
extent
of
the
procedure.
|
|
|
|
| The
Human
Tissue
Act
permitted
the
retention
of
organs
and
tissues,
providing
there
was
'no
objection'
from
relatives.
This
wording,
as
Chapter
5
noted,
is
subtly
but
importantly
different
from
'with
consent',
but
it
carries
the
implication
that
steps
are
required
to
see
if
the
relatives
have
objections
to
organ
retention.
|
|
|
|
| How
many
relatives
were
actually
asked
if
they
had
objections
to
tissue
or
organ
retention
during
the
period
1961
to
1995
will
never
be
known.
In
those
years
it
was
generally
assumed
that,
in
consenting
to
the
post
mortem,
the
relatives
also
had
no
objection
to
retention
of
tissues
or
organs.
The
consent
forms
rarely
referred
to
retention,
Chapter
42.
It
appears
from
the
recollections
of
relatives,
and
of
those
who
spoke
to
them,
that
the
question
of
retention
was
infrequently
mentioned
when
relatives
were
asked
to
sign
the
post
mortem
consent
form.
|
|
|
|
| Until
media
publicity
was
given
to
organ
and
tissue
retention
it
was
unusual
for
the
relatives
to
place
restrictions
on
the
extent
of
the
examination,
or
on
the
retention
of
tissues.
|
|
|
|
| The
present
position
is
very
different.
Many
relatives
are
only
prepared
to
agree
to
a
hospital
post
mortem
provided
it
does
not
include,
for
example,
the
opening
of
the
skull
or
the
retention
of
any
organs
or
tissues.
|
|
|
|
| Relatives
should
therefore
always
be
asked
about
tissue
and
organ
retention
to
ensure
there
are
no
objections.
|
|
|
|
| The
main
differences
between
Coroners'
and
hospital
post
mortems |
|
|
|
| The
two
main
differences
between
Coroners'
and
hospital
post
mortems
are
consent
and
prior
knowledge
of
the
cause
of
death.
|
|
|
|
| Consent |
|
|
|
| For
the
relatives
the
main
difference
is
that
their
consent
is
required
for
a
hospital
post
mortem
but
they
have
no
choice
in
the
matter
when
the
Coroner
orders
a
post
mortem.
For
relatives,
particularly
those
with
religious
objections
to
post
mortems,
this
difference
is
stark.
|
|
|
|
| Prior
knowledge
of
the
cause
of
death
|
|
|
|
| For
the
pathologist
the
main
difference
is
that
in
most,
but
not
all,
Coroners'
post
mortems
his
task
is
to
discover
the
cause
of
death.
By
contrast,
in
a
hospital
post
mortem
the
cause
will
already
be
known.
If
this
is
not
so
the
death
should,
by
definition,
have
been
referred
to
the
Coroner.
|
|
|
|
| For
the
Coroner
identification
of
the
cause
of
death
is
the
foremost
objective,
and
the
decision
to
order
a
post
mortem
examination
is
for
that
sole
purpose.
However,
Coroners
are
not
obliged
to
order
a
post
mortem
if
there
are
alternative
ways
of
identifying
the
cause
of
death.
|
|
|
|
| The
Coroner's
responsibilities |
|
|
|
| Rule
36
of
the
Coroners
Rules
deals
with
'matters
to
be
ascertained
at
inquest':
|
|
|
|
| 'The
proceedings
and
evidence
at
an
inquest
shall
be
directly
solely
to
ascertaining
the
following
matters,
namely:
|
|
|
|
a)
who
the
deceased
was;
|
|
b)
how,
when
and
where
the
deceased
came
by
his
death;
|
|
c)
the
particulars
for
the
time
being
required
by
the
Registration
Acts
to
be
registered
concerning
the
death'.
|
|
|
|
| For
deaths
where
there
is
no
inquest
the
Coroner
still
needs
to
answer
these
questions,
|
|
| and
(b)
and
(c)
both
relate
to
the
cause
of
death.
|
|
|
|
| It
does
not,
however,
follow
that
a
post
mortem
examination
is
the
only
way
to
answer
these
questions.
Nor
does
it
follow
that
if
an
examination
of
the
body
is
ordered
there
must
be
a
'full
post
mortem'
and
that
organs
and
tissues
must
be
retained,
though
this
may
be
necessary
in
some
cases.
|
|
|
|
| Deaths
referred
to
Coroners |
|
|
|
| The
majority
of
deaths
referred
to
Coroners
are
sudden
and
expected
deaths
of
unknown
cause.
In
the
minority,
the
cause
will
be
known
when
deaths
are
reported
for
other
reasons,
for
example,
following
an
accident
or
a
death
during
a
surgical
procedure.
In
such
cases
the
cause
of
death
is
known
but
the
Coroner
still
needs
to
satisfy
Rule
36
on
'how
the
deceased
came
by
his
death'.
|
|
|
|
| For
deaths
of
unknown
cause
the
Coroner
needs
to
decide
whether
the
cause
can
be
satisfactorily
established
by
reference
to
the
deceased's
existing
medical
condition(s).
|
|
|
|
| In
many
such
cases
the
probable
cause
of
death
becomes
clear
once
the
deceased's
medical
history
is
available.
The
Coroner
can
then
decide
whether
this
information
is
sufficient
without
resorting
to
a
post
mortem.
Chapter
44
considers
other
means
through
which
Coroners
could
answer
the
questions
posed
by
Rule
36.
|
|
|
|
| Thus
for
the
Coroner
and
for
relatives
the
important
question
is
whether
a
post
mortem
examination
is
needed
and
if
it
is,
the
scope
of
the
examination.
|
|
|
|
Objections
by
relatives
to
Coroners'
post
mortems
|
|
|
|
| A
coroner
has
the
authority
to
order
a
post
mortem
examination
in
any
death
reported
to
him.
The
Coroner's
right
to
insist
on
an
examination
is
an
essential
legal
safeguard.
|
|
|
|
| As
Chapter
42
indicates,
however,
many
pathologists
consider
a
'full
post
mortem'
should
be
routinely
undertaken.
In
deciding
that
a
post
mortem
is
necessary,
against
the
wishes
of
the
relatives,
the
Coroner
will
need
to
decide
between
a
full
post
mortem
or
restricting
the
extent
of
the
examination.
Many
Coroners
have
indicated
their
preference
for
respecting
the
objections
of
relatives,
provided
a
limited
post
mortem
satisfactorily
identifies
the
cause
of
death.
|
|
|
|
| Once
the
cause
of
death
has
been
identified,
the
Coroner's
purpose
is
satisfied
and
so
is
Rule
36.
It
is
difficult
to
see
how
continuing
to
a
full
post
mortem
can
be
justified
in
these
circumstances.
'Routine
procedure'
and
'medical
curiosity'
are
insufficient
to
justify
further
disregard
of
the
wishes
of
the
relatives.
|
|
|
|
| The
same
principle
should
apply
to
the
retention
of
organs
and
tissues
from
a
Coroner's
post
mortem.
These
should
only
be
retained
when
they
are
relevant
to
the
cause
of
death.
|
|
|
|
| Chapter
45
illustrates
the
difficulties
that
post
mortem
examinations
pose
to
some
religious
faith
communities.
The
experience
in
coronial
districts
where
relatives
have
been
assured
the
examination
will
be
limited
to
the
minimum
necessary
has
shown
that
this
alone
eases
the
objections
of
some
relatives.
|
|
The
hospital
post
mortem
|
|
|
|
| The
situation
is
different
in
a
hospital
post
mortem.
The
purpose
of
the
procedure
is
to
examine
the
extent
of
the
disease
that
led
to
death,
to
look
for
unexpected
features,
and
to
confirm
the
cause
of
death.
In
a
proportion
of
cases
the
cause(s)
will
be
revised
as
a
result
of
the
examination,
but
it
is
rare
for
a
hospital
post
mortem
to
discover
that
death
was
not
due
to
natural
causes.
|
|
|
|
| In
a
hospital
post
mortem
it
has
been
the
practice
since
1961
to
carry
out
a
full
post
mortem,
including
examination
of
the
brain.
|
|
|
|
| Pursuit
of
knowledge |
|
|
|
| As
medical
knowledge
advanced,
it
was
found
that
a
better
understanding
of
the
direct
and
indirect
causes
of
death
could
be
learned
from
post
mortem
examinations.
When
deaths
occurred
in
hospital,
doctors
increasingly
wished
to
learn
from
post
mortem
examinations
to
confirm
their
diagnosis
and
to
identify
any
other
unrecognised
factors
that
contributed
to
the
cause
of
death.
As
a
result,
in
many
hospitals
post
mortem
examinations
were
regularly
requested.
Before
1961
some
hospitals
even
included
consent
to
a
post
mortem
as
a
condition
of
admission.
|
|
|
|
| Many
advances
in
medical
knowledge
and
in
the
care
of
patients
have
come
directly
from
the
findings
of
post
mortem
examinations.
The
importance
and
value
of
the
post
mortem
and
its
contribution
to
better
patient
care
cannot
be
underestimated,
Chapter 46.
|
|
|
|
| Summary |
|
|
|
| There
are
different
purposes
for
Coroners'
and
hospital
post
mortem
examinations.
These
differences
have
become
blurred
by
the
policy
of
carrying
out
a
'full
post
mortem'
in
all
cases.
|
|
|
|
| The
distinction
is
particularly
important
when
the
relatives
are
opposed
to
the
examination.
|
|
|
|
| Coroners'
post
mortems
are
mostly
undertaken
to
establish
the
cause
of
death,
but
once
a
cause
has
been
found,
there
is
no
justification
to
extend
the
scope
of
the
examination
against
the
wishes
of
the
relatives.
|
|
|
|
| A
more
limited
post
mortem
examination
may
ease
the
difficulties
of
some
relatives
who
have
religious
or
other
objections
to
the
examination.
|
|
|
|
| In
many
Coroners'
cases,
organ
retention
is
not
necessary
to
establish
the
cause
of
death.
Where
retention
is
necessary,
the
extent
should
be
limited.
|
|
|
|
| The
Human
Tissue
Act
requires
the
consent
of
the
relatives
for
a
hospital
post
mortem
and
lack
of
objection
to
tissue
and
organ
retention.
|
|
|
|
| The
cause
of
death
will
be
known
before
a
hospital
post
mortem.
Otherwise
the
death
would
have
been
reported
to
the
Coroner.
The
purpose
is
to
confirm
the
cause
and
to
find
out
if
there
were
any
other
significant
features
of
the
death.
|
|
|
|
| Hospital
consent
forms
have
in
the
past
not
referred
to
organ
retention
but
consent
for
this
was
assumed
when
the
relatives
agreed
to
the
post
mortem.
|
|
|
|
| The
hospital
post
mortem
was
usually
a
full
post
mortem,
but
relatives
can
place
restrictions
on
the
extent
of
the
examination.
|
|
|
|
| Enquiries
should
always
be
made
to
ensure
the
relatives
do
not
have
objections
to
organ
and
tissue
retention.
|
|
|
|
| The
importance
of
post
mortem
examinations
in
contributing
to
medical
knowledge
and
to
improvements
in
patient
care
cannot
be
underestimated.
|
|
