Forensic pathology services

Forensic pathology services are an essential part of systems of investigating deaths worldwide. In England and Wales these forensic services, the entire death investigation system, and the coroner service are currently under review. Forensic pathology in Britain has had chronic problems as an orphan specialty excluded from the NHS at its inception and now largely ejected from the universities. Today the 35 or so pathologists accredited by the Home Office are contracted to police forces to support the investigation of suspicious deaths and homicides. About half are in full time private practice. They also provide autopsy services to local coroners, but most of the 120 000 coroner's autopsies performed annually are carried out by NHS pathologists as an approved form of private practice.¹

The chronic problems of the forensic pathology service have now precipitated a review by the home office. There has also been a recent flurry of scandals. The conviction of the serial killer Dr Harold Shipman, the furore over the retention of organs at autopsy, and the inquiry into the cutting off of the hands of victims in the Marchioness disaster² all exposed failings in the death investigation system. Australia is facing similar problems,³ and there has already been a review of the coroner service in the Republic of Ireland.

The Alder Hey organ retention scandal showed that monitoring physicians' performance is necessary to ensure good practice. In clinical pathology the setting of standards and peer review through external quality control is normal practice, but this is not the case with much of forensic pathology. There is little hard data on the quality of medicolegal autopsies in England and Wales because there is no system of audit. The confidential inquiries into maternal deaths and into perioperative deaths have identified some deficiencies,⁴ but these audits involve a select and small percentage of the coroner's total caseload. There are some general indicators to suggest that quality may be poor. Coroner's autopsies are done in mortuaries, in which there is recognised underinvestment.⁵ These facilities rarely have x ray or fluoroscopic equipment, stereomicroscopes, alternative light sources, or other modern equipment. Guidelines from the Royal College of Pathologists allow mortuary technicians to dissect bodies and remove organs in the absence of the pathologist.⁶ Linked to this practice is the large number of autopsies performed in a very short time by some pathologists. For a whole time pathologist the recommended workload for medicolegal autopsies ranges from 300 to 600 a year, depending on the proportion of suspicious and other challenging cases. Caseloads of pathologists that exceed these figures inevitably raise the question of how quality is maintained and assured. The current system of “fee per item of service” in the absence of enforced standards is an invitation to bad practice. Coroners should not allocate excessive numbers of autopsies to individual pathologists, and the total caseloads of pathologists should be monitored.

There are international guidelines and standards specifically for medicolegal autopsies,⁷,⁸ and the Home Office issues guidelines on autopsies of suspicious deaths to its accredited pathologists. By contrast the autopsy guidelines of the Royal College of Pathologists encompass both hospital and medicolegal autopsies, to the detriment of the latter, and the statutory format for a coroner's autopsy report is woefully inadequate.⁹ After appropriate standards have been set there will still be problems in auditing medicolegal autopsies. The autopsy is destructive, the body is disposed of, and the pathologist creates the only record. Requiring that pathologists follow a protocol, and include detailed negative findings in the report to show that they have done so, is an approach applied in Austria and Germany since the 19th century. In Finland a computerised database enables comparison of individual pathologists' practice using these reports.

Pathologists who work for the Home Office might be expected to do better than those who work for the NHS, but there are problems here also. Their work is subject to only limited audit by the Home Office. There is also a natural reluctance to question their competence in an individual case. They are, after all, qualified, accredited by the Home Office, experienced, and well tested in the courts. Apprehensions about the impact of an allegation of incompetence on previous criminal convictions and public confidence in the criminal justice system may influence the approach of the police and the legal authorities. This is claimed to have been the case with respect to a senior South Australian forensic pathologist.¹⁰ Pathologists who work for the Home Office can and do make serious errors. The Criminal Cases Review Commission for England and Wales is uncovering errors by pathologists. A recent trial of a dentist and an anaesthetist for the manslaughter of a 5 year old due to gross negligence folded when the pathologist admitted making a diagnostic mistake.¹¹ Pressure groups such as Miscarriages of Justice Organisation, Innocent, and Inquest have asked that the existing lack of quality assurance in forensic pathology be addressed. At present the Home Office has no effective mechanism to withdraw the accreditation of allegedly incompetent forensic pathologists, as the collapse of its first disciplinary hearing illustrates.¹²

Currently in England and Wales there is no clear organisational responsibility for the oversight of forensic pathology services to coroners and the police. The Home Office review of forensic pathology services is considering their management by an executive agency. This would place management within a government department but at arm's length and operating as a business. If implemented, this would be a welcome first step. The creation of a National Board of Forensic Medicine in Sweden in 1991 had a noteworthy impact in establishing uniform standards throughout the country. A new forensic medicine agency for England and Wales could achieve the same, but will first need to address the accumulated problems of half a century of neglect.