Death cases – A thematic report on liaison in death cases with particular reference to organ retention

Contact was made throughout Scotland with a wide variety of medical personnel including Forensic Pathologists and NHS Pathologists who do forensic work. In particular contact was had with the 4 Departments of Forensic Medicine at Aberdeen University, Dundee University, Edinburgh University and Glasgow University. A full list of those who contributed is contained in Annex 2.

We stress these are views put forward by certain service providers. We comment on them in Chapter 9.

As previously stated the Procurator Fiscal may instruct a post mortem dissection of a body in certain cases. A warrant from the Sheriff used to be obtained for this but this is now done on the instructions of the Procurator Fiscal. Full post mortems are undertaken by either one or two pathologists. Two doctors are usually used in cases where there is a likelihood of criminal proceedings and where the cause of death may be a critical issue at any trial. Post mortems raise, of course, the possibility of retention of organs and the possibility of donation. We consider this in greater detail in Chapter 6.

There has been previous widespread concern, as noted elsewhere in this report, regarding retention of organs without the knowledge of the next of kin. A number of contributors to this report were at pains to make us aware of the hurt they had endured as a result and in some cases were still enduring

"I did not find out until 5 years later that his brain had sat in a cupboard and nothing done."

The system now is based on full disclosure and the overwhelming weight of evidence we received in preparing this report is that retention for diagnostic purposes (ie to ascertain the cause of death) is now a rare event. We have elsewhere updated the information on the number of post mortems which take place in Scotland and the number of organs retained. The term "retention" is itself capable of ambiguity. We use the term in this report normally only to cover those situations where an organ (or other material) has been retained beyond the release of the body back to the next of kin. Where, for example, an organ is retained for a very short period and then returned to the body prior to its release then that is not in our opinion properly described as "retention".

The dramatic drop in recent years in the number of hospital post mortems has been highlighted to us as causing considerable difficulty in the training of pathologists and the reduction of the number of organs retained (for research as opposed to diagnosis) is potentially having an impact on medical research.

"Getting experience is a problem."

We visited one particular project designed to try and alleviate this problem in Edinburgh at the Western General Hospital. There a team of neuropathologists under the leadership of Professor Jeanne Bell have made special arrangements with the Crown Office and with the local Procurator Fiscal in Edinburgh to have access to next of kin in cases where a death has been reported to the Procurator Fiscal. Basically the system allows Professor Bell and her team to approach the next of kin where there is a Fiscal post mortem with a view to the team retaining material, normally brains, for research purposes.

It was highlighted to us by the team that there is no real shortage of "diseased" brains for research as many people who suffer from disease are willing to donate their brains for medical research purposes but there is a dearth of "normal" brains for comparison purposes.

"Normal samples are needed. One problem with studies is they need something to compare it with. There is a worldwide shortage of normal brains for use in research."

In Edinburgh in practice the system is that once the team has been advised of the necessity to carry out a Fiscal post mortem a nurse co-ordinator from the team makes contact with the family. This is normally by phone but can be in person. The nature of the request is put to the family and, of course, full disclosure is made of the purposes of the proposed retention. In contrast to that system one member of the team explained that in hospital post mortems there has to be very clearly defined "consent" - the form being very specific and lengthy. Rates of consent (following Alder Hey etc) for hospital post mortems were described as having initially fallen but starting to rise again. It was explained to us that the success rate in getting authorisation from relatives in this project is currently running at about 95% which is largely put down to the method of approach and the total transparency.

"The problem in the past was because people were not told … the need for human tissue for research is vital and we need high quality material with the relatives' consent."

It was described to us that many Fiscals did not understand the process which the pathologists followed and were not aware how blocks and slides were formed and similarly the same problem arose with the Police. The question was then posed by the team as to how the Procurator Fiscal or the Police could explain this to families if they did not know the process themselves.

"There is now close communication between the medical and legal staff, which did not exist before. We learn their role and they learn ours."

We were also informed that there was in Scotland a golden opportunity to co-ordinate this kind of research as the existence of the Procurator Fiscal Service with a centralised headquarters in the form of the Crown Office enabled negotiations to be made with a single unitary body. In contrast, in England because of the separate jurisdictions of Coroners similar exercises would require separate agreements with all the individual Coroners.

"My wish would be that this is seen as a national resource and funded as a national resource by the Scottish Executive rather than by research bodies, it is a unique high profile facility that Scotland is giving to the world."

The team were also very interested in getting involved in the training of Police and Fiscals.

This project in Edinburgh is, in our opinion, an excellent example of good joint working between the medical and legal authorities for the benefit of society as a whole. It involved close liaison with next of kin, the Procurator Fiscal being the bridge between the research team and the next of kin. The question of funding is for others to decide but we would strongly recommend this as an example of good practice.

Another group of health professionals were concerned with the way maternal deaths were investigated and reported to the Procurator Fiscal. They were keen to make maternal deaths a mandatory "must report" category of deaths to the Procurator Fiscal. Their view was based on the impact such deaths have for both the families involved and staff. Current statistics show that these run at about 10 per year in Scotland. A number of these, but not all, are reported to the Procurator Fiscal and post mortems instructed. If the mother dies in hospital and the death is not sudden or unexpected it would not under the current guidelines be necessary to report such a death to the Procurator Fiscal although the doctors would obviously be free so to do.

So far as definitions are concerned the team were keen to describe maternal deaths as those which occurred within 12 months of the birth to capture, for example, deaths resulting from post natal depression. Their view was that all such deaths should be followed by a post mortem. One statistic given to us is that maternal deaths are over-represented in statistical terms in the minority ethnic population where there might be added cultural or religious reasons discouraging post mortems. The lack of consistency in the way maternal deaths were dealt with was contrasted by the team with SIDS (Sudden Infant Death Syndrome) deaths where there was guidance from the centre and less variability.

We recommend that the Crown Office and the relevant medical authorities take forward discussions on this particular topic.

Information was also provided by medical staff at a meeting in the Royal Alexandra Infirmary in Paisley. Some concern was expressed that there was a lost opportunity in Fiscal post mortems for organ donation although recent experience with heart valves and corneas was described as good.

The reduction in hospital post mortems was seen as a problem as was a lack of information back to the hospital in cases where a patient had died and the Procurator Fiscal had instructed a post mortem. De-skilling and lack of experience of pathologists was also highlighted as a problem as mentioned elsewhere.

"Our pathologists are getting more and more reluctant to do post mortems and they do so few that they don't feel skilled enough. It is quite traumatic for them to do them now there is a lack of post mortems."

It was reported that the hospitals did in the past do Fiscal post mortems but on the basis of the new forensic medicine contract only Forensic Pathologists were doing them now. This occurred at the same time as the number of hospital post mortems was reducing.

"Now the norm is not to have a post mortem (ie a hospital post mortem). Pathologists are required to do other things, eg on the spot breast cancer diagnosis, the slant of the job has changed there is a shortage of pathologists."

It was explained that after Alder Hey behaviour changed and people became more wary of post mortems. The authorisation requirements also meant that "consent" went from a single sheet to a 10-page booklet.

"When you are faced with grieving relatives it is the last thing you want to do. In more cases we can get a diagnosis - CT scans - but there are a group of patients when it would be nice to know."

Some concern was also expressed on the question of Fatal Accident Inquiries and the impact these can have on medical staff and we were informed that liaison for witnesses in Fatal Accident Inquiries did not work particularly well in practice locally.

Further concern was expressed over "critical incident reviews" which take place when a case is reviewed by the medical staff to ascertain what had happened and what lessons could be learned. In the past these were based on a free and open exchange of views but more recently these had become inhibited because of the possibility of the information discussed at the review coming into the public domain and possibly being used in court proceedings.

In the Lothians relations between the NHS hospitals there and the Procurator Fiscal were described as generally very good and since 1999 we were informed that the hospitals had had a policy to encourage doctors certifying a death to positively consider whether the death should be referred to the Procurator Fiscal. A form was devised to go into each case note reminding doctors that they had to record a proper medical diagnosis as being the cause of the death.

Some practical difficulty was experienced, however, in cases where a person had died in hospital and the Procurator Fiscal had instructed a post mortem. It frequently fell to hospital staff to explain to the relatives what the arrangements were for the post mortem albeit it was a "Fiscal" as opposed to a "hospital" post mortem. As elsewhere some concern was expressed that the results of the post mortem were not always fed back to the appropriate medical staff. This can on occasion inhibit meetings between the hospital staff and the next of kin which sometimes have to be delayed until the post mortem results are known. Some concern was also expressed that medical staff possibly under-report deaths to the Procurator Fiscal.

As elsewhere the number of hospital post mortems was described to us in Lothians as having declined very much in recent years. This was not all put down to publicity surrounding Alder Hey etc but in some cases because of increased diagnostic ability in life such as CT and MRI scans to such an extent that it was described to us as unusual nowadays for there to be any puzzle as to why someone has died in hospital. It was explained that surgeons are now the most likely category of doctors to request post mortems whereas in the past geriatricians tended to have requested the most post mortems.

"We are missing the prevalence of some diseases because we don't do post mortems."

The significant shift in procedures for post mortems was highlighted to us. Obtaining agreement to a post mortem in the past had apparently been straightforward, the doctor going through with the family what had happened and indicating that a post mortem would help to find things out and might help others. There would be no discussion of organ retention or that material could be kept for teaching.

It was described to us that the new requirements meant that the majority of doctors were reluctant, it took much longer and a detailed discussion was needed with the family. The new authorisation form was described, however, as much better, giving the public a clearer understanding but that it could limit the investigation and was more explicit. The medical staff who obtain this agreement felt the process was better but doctors could be put off the process of asking due to the increased requirements. They had to weigh up the benefit of spending the time for what might be obtained.

Post mortem rates on children remained, however, as high as ever because deaths in children were relatively uncommon. Doctors believed that the new process here was much better, it took longer but the gains were considerable.

We were told that in hospital post mortems not many organs were retained (see separate statistics) and certainly very few whole organs.

In relation to Fatal Accident Inquiries the role of the NHS Central Legal Office was to co-ordinate work for the NHS including time lines and issues to be addressed. It would liaise with the Procurator Fiscal and the solicitor for the family if there was one. Obviously agendas between the professionals and the family might differ. It was confirmed that if there had been an internal hospital inquiry then the findings would be passed on to the Procurator Fiscal.

The issues surrounding organ retention were described as having a huge effect on the NHS. The McLean Report was described as a driver to change practice, first in children's services and then in adult services. Common documentation was now being used by all NHS hospitals which had not been the case before. The down side was described as the decline in the number of post mortems but it was indicated that had been happening anyway because of increased diagnostic techniques. It was not agreed that the increased bureaucracy was stifling research and teaching. What there was now was transparency and openness.

Some concern was expressed where a case was subject to legal process that there could be a difficulty in getting information to be shared until the legal process was finished. Speedier feedback might be helpful particularly, for example, in the case of children where it was regarded as good practice to meet with the bereaved parents at about 6-8 weeks after the death and take them through the circumstances. If there had been a Procurator Fiscal post mortem this could not always be done as the information might not be available until later. Therefore the same level of service to bereaved families could not be offered in the case of a Fiscal post mortem as opposed to a hospital post mortem.

We recommend that in Fiscal post mortems the results and copies thereof should be shared with the appropriate medical authorities as soon as possible.

Contact was also had with Dr Gray of Aberdeen Royal Infirmary who specialised in what was normal or abnormal in children up to 15 years. She carried out about 10 post mortems a year for Procurators Fiscal. In addition she dealt with neonatal deaths although most of these came through the hospital post mortem route rather than the Procurator Fiscal unless there was a suggestion of criminality or neglect.

She also confirmed that the number of post mortems had dropped dramatically since the organ scandal particularly in the age group with which she was concerned.

Liaison arrangements between herself, the local Forensic Pathologist and the Procurator Fiscal were described as good. Liaison with next of kin was normally by the Fiscal or by the Forensic Pathologist.

She described the arrangement (fairly universal) whereby if something suspicious arose during a post mortem which she was doing alone she would stop the post mortem and get the Forensic Pathologist and Police involved and move to a two doctor post mortem.

So far as organ retention was concerned in Procurator Fiscal post mortems (all done at the Police mortuary), the parents were usually asked to attend to carry out an identification which gave the Forensic Pathologist a chance to speak to them. She thought that some misunderstanding had arisen in the past about retained organs in Fiscal post mortems because the parents did not understand that they were Fiscal post mortems as opposed to hospital post mortems.

She described how prior to the organ retention problem it was believed to be good practice to retain the brain for full pathological examination. Brains were kept for examination after being fixed and no-one would be advised. It was a different culture then.

Current practice in Fiscal post mortems was that the Forensic Pathologist would explain to the parents if the brain had to be retained. Clearly they had no choice in these situations but it was a distressing experience and it needed to be explained to them. In addition, the various options about disposal thereafter would be explained to them. The same choices were extended to the next of kin in Fiscal post mortems as in hospital post mortems regarding ultimate disposal of any retained material. Dr Gray felt that the most common option was to delay a funeral to allow body parts to be reunited prior to burial. She thought that so far as who was best placed to explain this to the next of kin, in her opinion, it was local pathologists either herself or the Forensic Pathologist.

She did on occasions, as did the Forensic Pathologist, attend meetings with parents after a post mortem. She said she found it useful that the Procurator Fiscal was present.

Although there was pressure now not to retain organs such as brains this could cause some problems. Normally a number of standard blocks from parts of the brain were removed and the brain then returned. After the brain had been returned if something turned up from the blocks it was of course impossible to go back and take further samples. That was described as a weakness in the current situation.

"With the long-term fix you can go back and take more samples and get the whole picture."

Obviously this would not apply in suspicious cases where the brain would be retained in appropriate cases.

Dr Gray indicated that she did not do defence post mortems but she knew that these can on occasions delay release of the body. A point also made to us by a Police Family Liaison Officer. There is a particular shortage in Scotland of paediatric pathologists.

Indeed the difficulty of defence post mortems was highlighted to us on several occasions.

Overall, Dr Gray indicated that she was happy with the current arrangements on liaison and that she preferred to do post mortems in the Aberdeen hospital mortuary as opposed to the Police mortuary although the latter would have to be used for suspicious deaths.

Information was also received from Mr Robert McNeil, Divisional Mortuary Services Manager for North Glasgow University NHS Hospital Division based at Glasgow Western Infirmary and Chair of the Association of Anatomical Pathology Technologists UK.

He described how following the McLean review and the audit undertaken by NHSQIS that a retention protocol was implemented. Databases now tracked in great detail anything that had been retained. Every specimen was removed from hospital and stored in "respectful storage" in a ward in Stobhill Hospital. Mr McNeil raised the question of what was to happen after the 5-year moratorium came to an end. He indicated it would be a huge dilemma for the NHS to decide what to do with all of the specimens. He felt that as a former Curator of the museum that it would be a tragic waste if all the specimens were lost. (Since our meeting with Mr McNeil Glasgow University has apparently agreed to take responsibility for the collection.)

"A lot of these specimens are unique pathology specimens which could be used for exam purposes for mortuary technicians and pathologists if not used for teaching. To lose them is to lose a great part of history."

Again the lack of post mortems was highlighted as they were not now routinely being asked for by clinicians as they have to get informed "consent". Mr McNeil thought there would be a great benefit in bereavement services being offered to relatives in Scotland as happened in England. Only Yorkhill Hospital had such a service in Scotland. In England every Trust had it following Alder Hey. Services could vary but typically took the family through the "consent" procedure and could involve speaking to clinicians, pathology and mortuary staff who could give information to relatives. If there was information provided via such bereavement services it was more likely that "consent" to a post mortem would be given.

Again highlighted to us was the increasing tendency over the last few years for pathologists or trainee pathologists to be less involved in post mortem work and to be more involved in diagnosis.

Another concern expressed to us was the level of "consent" in hospital post mortems where it was not uncommon for relatives to give only limited "consent". There was a danger that the Fiscal is relying on that information and it might be incomplete and sometimes it could not establish the exact cause of death because the pathologist could not examine all of the organs.

The Care of Bereaved Group had been set up in Glasgow. It looked at a wide variety of initiatives to try to make the process of death more acceptable to the public and to provide support to nursing and other staff.

One of the main remits was to see what could be done in providing bereavement services. There were issues around who should pay for it. One idea was to create a bereavement centre where health professionals and a Bereavement Officer could take the family through the process and pathologists and transplant co-ordinators, if necessary, could be involved. One benefit of the Care of Bereaved Group was that issues cropped up that could be dealt with there and then instead of through the complaints procedure.

Mr McNeil indicated that the rate of organ retention or tissue retention was now negligible and that pathologists were now "terrified" of keeping anything.

Mr McNeil indicated that he had been asked to speak to medical students regarding death certification and the "consent" process for post mortems. Prior to this there was no specific medical student training on this subject. Professor Sheila McLean had recommended in her report that senior doctors/consultants approach for "consent" but it just did not happen. Often, Mr McNeil said, it was left to the junior doctors who contacted him and said their consultant has asked them to get a post mortem and they were asking for information on how to do so. He described how it all came down to consultation and proper communication.

Some concern was expressed that Fiscals put pressure on junior doctors to have hospital post mortems done as it would be quicker and that in turn put pressure on the relatives to agree to a hospital post mortem.

Mr McNeil was concerned that there was a potential for missing out on transplant material in Procurator Fiscal cases. One centralised mortuary would assist in that regard.

In Fife information was supplied by the Medical Director, Dr Birnie.

Echoing points made by Mr McNeil, Dr Birnie indicated that when he had worked in England there was a Bereavement Officer who could contact the next of kin and deal with all the forms etc and that they were currently looking for the creation of such a post in Fife.

In cases where a patient had died in hospital and it was referred to the Procurator Fiscal some information would be given by the hospital staff regarding the involvement of the Fiscal but then generally the hospital would step back.

Liaison with the Procurator Fiscal in Fife was described as good. Again echoing earlier concerns Dr Birnie thought it would be an improvement if the results of a Fiscal post mortem could be given or at least given sooner. Any staff who wished to get a copy of the post mortem report usually had to contact the Procurator Fiscal. This was particularly useful in medical misadventure cases. One difficulty highlighted by Dr Birnie was the involvement of the Police in Fiscal cases which tended to make the next of kin and family think that it was a criminal investigation and that in some way the doctor had killed the patient.

Overall, Dr Birnie thought that a bereavement service would be very useful. It was difficult for hospital staff after losing a patient to find the time to speak to the next of kin. A Bereavement Officer could however make an appointment to see the family and take matters forward.

The relationship between NHS Fife, the hospitals and the Procurator Fiscal was good. Any individual problems were often due to a lack of communication between individuals and were not a systemic problem.

Information was also received from Professor Stewart Fleming of the Royal College of Pathologists.

Professor Fleming told us that generally pathologists working in the autopsy field would be happy to talk to relatives but to his knowledge this was only routine in some specialist centres.

He highlighted that in the past liaison was probably not done well in relation to giving information on retention of tissue and organs. For example, for most diseases affecting the brain optimum pathology was obtained if the brain was retained and fixed for about 6 weeks. That was not something that the public or indeed even some professionals were aware of and liaison to explain that might have been helpful.

Taking of samples for histology (histology is the examination of tissue under the microscope) was recognised as good post mortem practice across Europe. The Royal College and its European counterparts have protocols that samples should be taken and kept as part of the record of the post mortem. Subsequently anyone could go back and review as necessary. This could even assist the healthcare of relatives.

Under the new Human Tissue Act blocks and slides were to be retained as part of the health record and this allowed clinicians to conduct a review. This also now meant that there was a permanent record of the post mortem through the blocks and slides. This contrasted with organs which were replaced in the body which then were buried or cremated and could not, therefore, thereafter be further examined. Professor Fleming was of the view that the permanent record was useful from both the legal and health point of view.

It was highlighted that there were problems around record keeping and that it was necessary for the Procurator Fiscal/ Pathologist/Crown Office and Health authorities to resolve these. He described how from a professional point of view one of the difficulties was sometimes linking findings and outcomes from the Procurator Fiscal post mortem to the patient's health records, getting the information into the health records or the health records for the Fiscal.

Once the post mortem was instructed it normally took place within 3 days but sometimes it could take that length of time to get the case records together as these could be located in several different sites. Equally, getting the post mortem findings into the health records was also problematic. It did not affect the outcome of the post mortem but it could affect the family if they went to the GP to find out what had happened.

He indicated that as staff in the Fiscal's Office were not usually medically qualified they might not be best placed to talk through what post mortem findings might mean. The Professor would welcome a better liaison set-up, a formal procedure of interaction between the pathologist, Fiscal, family and Police.

He drew a particular distinction between post mortems on the one hand for natural deaths and on the other unnatural deaths with possible criminal prosecutions, the two being quite different.

In the case of natural deaths he thought the family would benefit from getting more information than they got at the moment once the pathologist had identified the cause of death.

He indicated that there was an informal mechanism when there had been a post mortem, the family through their GP (or through the hospital consultant) could speak to the pathologist.

Professor Fleming confirmed that far fewer organs were retained than previously.

He indicated that the people of North Fife and Tayside were particularly generous towards medical research and the medical school.

A number of initiatives in the North Fife and Tayside area had borne fruit, for example, all cancer patients were asked for permission for Cancer Research to use their tissue and it was very rare for anyone to refuse this.

In the post mortem field relatives were asked about the retention of tissues or organs for teaching purposes and again it was found that most people agreed to this.

Once it was explained to the families what was going to happen and why, most families were supportive. It was important for young doctors and nurses to see the effects of disease. This was mostly in the area of NHS post mortems but could apply equally to Procurator Fiscal post mortems.

Again, echoing previous contributors, Professor Fleming indicated that he thought Bereavement Officers were the way forward. The aim was to have a hospital bereavement officer as a point of contact and staff there could answer questions to a certain point or know the most appropriate person to ask.

Under the new contract agreed with the Crown Office the hospital pathologist would do Fiscal autopsies on hospital patients so any hospital liaison process could support these as well as normal hospital post mortems.

On the question of liaison with the Procurator Fiscal the Professor explained that some are exemplary and some less so and it could be variable. In his own area he dealt with 3 or 4 different individual Procurators Fiscal who could all do things slightly differently. He indicated that a standard way of operating with all Fiscals would be helpful.

On the question of "view and grant" post mortems the Royal College was reluctant to get involved in so far as this related to policy but if they were to be done the college would support training for them.

NHSQIS (Quality Improvement Scotland) supplied information from their perspective.

"It is not easy as there has to be understanding that there are certain things that the Fiscal has to do in certain cases so their deaths are not the same as a natural death."

NHSQIS wished to see:

• More joint training
• Training on bereavement issues and communication
• Common post mortem standards for Fiscal and hospital post mortems
• Common levels of communication with nearest relatives in Fiscal and hospital post mortems
• Greater understanding of the role of other professionals

"… People felt they were operating two different systems when dealing with relatives."

QIS had a number of other issues:

• A higher rate for refusal to junior doctors seeking authorisation of post mortem examination.

"Anecdotally if the clinical staff thought there were reasons for post mortem but the family didn't consent they would report these deaths to the Fiscal. Some pathologists said they had had Fiscal post mortems that should not have been. It was a question in people's minds."

• That Fiscals might not be up to speed with the more unusual ethnic and cultural customs surrounding deaths
• The reduced number of hospital post mortems.

"You ask why the numbers are down; people don't like to ask for authority because, anecdotally, the authorisation form is so complex."

Examples of good practice were given including in a Fiscal case a death where the family had a requirement that the body be left in the same position for 12 hours without being touched. The death happened in hospital and it was not possible to leave a body in a ward for that length of time. The Fiscal rang the local hospice and asked to use one of their quiet rooms to allow the 12-hour window and the hospice agreed.

NHSQIS welcomed the provisions of the Human Tissue (Scotland) Act 2006 which laid down that blocks and slides were now part of the medical record.

The British Medical Association reported that communication had improved and more pathologists were willing to meet with bereaved relatives.

Concern was, however, expressed about who in the future would approach families about future retention for education, research etc. in Fiscal post mortems.

"Authorisation is needed but mechanisms need to be put in place to ensure this is sought (in England there was some reluctance among coroners to take responsibility for this and so it seemed to fall between the responsibilities of different people)."

One NHS pathologist reported that as a pathologist dealing with adult deaths:

• Organ retention was exceptionally rare
• Fiscals locally had been reluctant to sanction retention
• The majority of neurological conditions could now be dealt with by histology alone precluding the need for retention.

His personal experience indicated that if relatives chose to delay a burial/cremation until completion of neuropathology (2-3 weeks later) to allow for the brain to be re-united with the rest of the body distress usually ensued with almost daily phone calls to the mortuary asking when the body would be released.

One medical contributor reported that the involvement of the NHS in Fiscal post mortems was less than previously. However, the NHS interacted with the Fiscal in many ways as pathologists in the NHS were involved in providing specialist pathology services (eg paediatric pathology) and there was contact between the NHS and Fiscals in hospital deaths.

Yorkhill Family Bereavement Service advised (echoing other comments) that families do not always retain information and that a leaflet with contacts would help.

The importance of the role of the Police was stressed.

"Family's perception of how they are treated usually depends on the Police who are involved with them. Therefore, it is important that they have a good experience and feel they can liaise with them."

Another NHS source described communication between the Fiscal and the next of kin as excellent. We were advised that in deaths where there was a suspicion of a complaint or a critical incident the Fiscal would have little interest in pursuing a Fatal Accident Inquiry if reassured that a full Critical Incident Inquiry had been held and steps taken to identify the root causes behind any failures of care.

One particular such case was highlighted to us as a result of which changes had been introduced and the family notified. In this case the family wrote to the Fiscal expressing their satisfaction in particular that their concerns had been taken seriously.

Views of Forensic Pathologists

As previously indicated there are 4 centres in Scotland for the provision of forensic pathology services under the auspices of the universities namely, Aberdeen, Dundee, Edinburgh and Glasgow. These posts typically are academic with the title of Professor of Forensic Medicine and related staff and traditionally there has been close contact between the Crown Office and these Departments including input by the Crown Office into the appointment of the Professor of Forensic Pathology.

As with other pathologists there was considerable evidence put to us of the shortage of trained Forensic Pathologists in Scotland. This has resulted in a practice of recruiting from England and further afield.

Input was obtained from Professor Pounder at Dundee University.

Although organ retention was an important issue Professor Pounder reported in terms of cases, numbers were very small. Even before the Alder Hey scandal Dundee did not retain much in the way of organs.

Professor Pounder's own view regarding material which was currently held by Dundee University (or in Scotland) is that it would do more harm than good to contact families. Because of the publicity anyone who had concerns would have made enquiries already. Dundee University have had enquiries going back 30-40 years. As far as those who have not pursued it he saw little point in potentially giving them a problem by pursuing it now.

So far as the present situation was concerned Professor Pounder felt inhibited about retaining organs and would only retain if absolutely necessary. Whether that affected the quality of the work was arguable but he suspected it did not.

In terms, however, of spin-off benefits he suspected it did.

Professor Pounder stated that when he trained he had access to 30 years of retained organs and pathology which was tremendous for training purposes. This was in the area of children's hospitals. Later he had an interest in cardiac pathology and also had access to a collection of hearts. So in terms of training and education he felt there was a problem but not in terms of the service given to the Procurator Fiscal.

A new (Crown Office) contract came into effect on 1 July 2006 and under this he had a specific arrangement to leave 100 Fiscal autopsies at Ninewells Hospital, Dundee for the hospital pathologists to perform so they could obtain post mortem practice. Otherwise hospital pathologists would have to come to the Police mortuary to train.

In Tayside, Fife and Central there was a system where most of the "natural" deaths were left in the hospital and only the "unnatural" ones taken to the city mortuary.

The result of this was that 100 post mortems would be done at Ninewells Hospital which previously would have been done at the Police mortuary. He thought this was the best "mix" for providing the service for the Fiscal and still leaving cases in hospital to maintain skills there. He has therefore pursued a collaborative relationship with the NHS in Dundee. NHS Pathologists provided a very good service.

He thought for Scotland as a whole the tendering process was a bit of a missed opportunity to pull the NHS Pathologists in with the Forensic Pathologists and to deal with competing interests.

The Royal College of Pathologists had stipulated that trainee pathologists had to conduct 25 autopsies a year and a number of hospitals just did not provide enough so he felt they had solved that problem in Dundee.

So far as retention was concerned Professor Pounder indicated that it had to be thought about very carefully and he went out of his way not to retain although it was still a thought in criminal cases but not the overriding issue.

Previously, tissue for histology had been retained from a variety of organs in all cases whether it was intended to process it or not so that it could be referred to again if necessary.

After the organ retention scandal it was only done if there was a real possibility that it might have to be referred to in the future and that was the current practice, so a very reduced amount for histology purposes was retained. These samples went into paraffin blocks.

In cases where there had been retention involving the Procurator Fiscal he did not liaise with the family but informed the Fiscal that there had been retention and he assumed that the Fiscal then dealt with the family.

There had been a recent breakdown in communications concerning a case where a brain had been retained but the Fiscal was not informed until after the body was released and therefore the family did not know. It did show up a failure of communication but it also highlighted the fact that the Fiscal communicated with the family by letter which caused him some concern.

Following from that recent problem he had, in communicating the retention of the brain to the Fiscal, devised a "tick box" system which at the end of the post mortem would be faxed to the Fiscal which would intimate retention. At the end of the autopsy a death certificate was faxed. Now the fax would include the form and the death certificate.

So far as liaison with the family was concerned Professor Pounder thought someone medical was probably better placed to do it. Inevitably questions would be asked on procedure and practical issues and he would be prepared to deal with these.

He thought the best system would be for the first contact to be by the Fiscal regarding retention but then an explanation given that the pathologist would contact the person and explain everything to them later or offer to let the pathologist deal directly with the undertaker. Inevitably undertakers had a very good relationship with families.

The pathologist was, in his opinion, in a better position to explain why there had to be retention and the various available options but the initial contact should be by the Fiscal. Retention was by the legal authority and the legal authority should make that contact.

He did get involved with families in Fiscal post mortems. Identification was always done through the pathologist and at that point the pathologist would meet the family.

After the post mortem he would only meet with the family if there was a problem with the case and the Fiscal wanted him to discuss it with the family and he would do that with the Fiscal present. He found he did most of the talking but the Fiscal was there as a facilitator and he was happy with that.

"The family wants to hear it from the horse's mouth, it may take an hour but once it is done it is settled."

The average number of organs retained in Dundee was between 3 and 5 a year. He thought the contact with the family in these situations should be oral and not written.

So far as he was concerned toxicology and histology were essentially destructive and the material obtained should be disposed of like surgical or hospital waste. It would not be disrespectful to the deceased to do so.

Organs like the heart and brain were different, due to social and cultural considerations, and were of important significance. Tissue and bodily fluid should be seen as a different issue.

Prior to the problem referred to the Fiscal was informed only if an organ had been retained and if there was no communication then it was assumed there had been no retention so any lapse in communication as occurred here meant that the Fiscal thought that nothing had been retained. He had communication with many Fiscal Offices so it was easy for mistakes to arise. This new system should ensure that these problems did not occur in the future.

Organs that are kept are stored in the Police mortuary in Dundee although the brain might need to go to Aberdeen for examination and then come back.

There are choices for what people want done afterwards. In Dundee the cremation rate for retained organs was about 80%. His view was that cremation changed people's views on what happened with organs. He could not think of a single case of anyone asking for any organ back.

He would have no objection to the post mortem report being sent to the GP. He did not know if they particularly made use of it. If he had to mail it to the GP he would need to know who they were and would also need the Fiscal's permission as the Fiscal had copyright over the document.

When he first came to Dundee the cause of death was in fact mailed to the GPs but he had stopped this practice and no-one appeared to notice which indicated to him a lack of interest. If there were real interest they would contact him and get the result. Anything else was just expensive bureaucracy.

He thought if the nearest relative was asking for the post mortem report it was better for them to speak to pathologists rather than the GP.

He did not have any problem with giving copies of the non-technical part of a post mortem. His view was that any member of the family should get access to the commentary but if they wanted the full report they should have it although they should be warned it could be unpleasant and technical.

At the moment nothing was sent electronically but if that was to be done there might be problems about security. In hospital cases where there may have been 2 or 3 consultants involved there would have to be some sort of central e-mail address, with the GPs there was no problem as the Police could get the name and address.

The main calls he did get were from hospital doctors and they could get the information immediately. All they needed was the key information and they could get that in the course of a phone call.

Professor Pounder reported that he was well aware that the organ retention scandal had created problems for organ donation.

There were no systems which would allow for permission for bone, skin and eyes to be donated in the way that they should. He thought it was not the role of the pathologist to do that.

In some countries large city mortuaries did facilitate donation such as in Melbourne and Calgary. It seemed to him that where there were large public mortuaries such as Aberdeen, Edinburgh and Glasgow it was a lost opportunity that they were not tied in with a tissue bank.

It had to be said though that, even if there were the maximum kidney donations from potential kidney donors who were dead, it would still not meet the demand and that might be true of livers also.

He thought there were lost opportunities probably not in the case of organs like the heart, lungs, kidney and liver but things like skin, cornea and bone which at the moment needed to be done in one or two centres to service all of Scotland.

It would be helpful to have legislation authorising the taking of these, it being difficult to approach an acutely bereaved person for such authorisation.

Information was also obtained from Professor Busuttil recently retired Professor of Forensic Medicine at Edinburgh University.

Professor Busuttil reported that in his experience pathologists were willing to meet with the family in Fiscal cases to explain what had happened and that such meetings were always successful.

He indicated no problems in liaison with the Procurator Fiscal's Office in Edinburgh and that there were good relationships.

Copies of post mortem reports could be given either directly to the family or through the GP. It was indicated that some GPs were keener than others to be involved in this activity.

The Pathology Department in Edinburgh carried out approximately 1300-1400 post mortems per year and this generated about 120 meetings with next of kin.

It was reported that in the past pathologists were discouraged from speaking with families at least until after court proceedings were concluded. However, as a result of the Dunblane public inquiry, measures had been put in place to communicate and keep in touch with families before and throughout proceedings.

In the recent cases of Jodie Jones and Rory Blackhall there had been particularly good liaison between the pathologist, Procurator Fiscal and next of kin. This liaison meant that there would be no surprises for the family when the evidence was heard in court whether it was a Fatal Accident Inquiry or a criminal prosecution although clearly there were restrictions on detail which could be provided to next of kin while there was an ongoing criminal case. The more distant Lockerbie case was cited as an example of bad practice where the relatives were not told anything and there was no liaison until after the conclusion of the court case by which time relatives were "queuing up at the door".

In murder cases families might still have questions to ask after the court proceedings were finished and pathologists who were going to meet the family members at this point could provide explanations etc.

Echoing previous contributors Professor Busuttil indicated that there was a lot of medical terminology in post mortem reports and Procurator Fiscal Office staff were not medically trained and might not know how to inform families and might even on occasion misunderstand the terminology.

Changes in personnel in the Fiscal Office Deaths Departments were highlighted as causing occasional problems, some staff being more adept than others in dealing with next of kin.

The Professor indicated that there was a perceived resistance from Fiscal Office staff where organs could be donated, for example, where there had been a death as a result of a head injury in a homicide case and the pathologist was satisfied that no other organs contributed to the death. Professor Busuttil reported that he had persuaded Fiscals to approve release of organs for donation in some cases.

Professor Busuttil suggested some improvements, one in particular being for Fiscal's Office staff to use the Pathology Department to explain terminology etc so that they could be better informed to speak with next of kin. It was also suggested there should be some selection criteria in choosing Fiscal Office staff in dealing with deaths.

Further it would be helpful for Fiscal staff dealing with deaths to stay in post for longer periods than in other Departments to build up experience. In particular Professor Busuttil felt that performance was better in Fiscal's Offices where there was a dedicated Deaths Unit.

Also the Professor indicated that Fiscals should be persuaded to consult pathologists more regarding possible organ donation in homicide deaths.

Professor Busuttil commented on the research project undertaken by Professor Bell at Edinburgh University and the high success rate in getting authorisation from next of kin to retain material in such post mortems.

Views from the University of Glasgow

A collegiate view was received from the Forensic Pathologists at Glasgow from Dr Clark.

Communications in Glasgow with Fiscal Offices (Glasgow serves most of the Fiscal Offices in the Strathclyde area) was generally very good particularly with the Glasgow Procurator Fiscal Office which benefits from having a dedicated Deaths Unit. The experienced nature of the staff in Glasgow was commented on as an important consideration given the relatively frequent turnover of Fiscal staff.

It was reported that there was concern about Forensic Pathologists being asked to carry out post mortems in cases where the purpose might be questionable. Invariably these were deaths where people had died in hospital where the hospital doctor was uncertain as to the precise cause of death although satisfied it was entirely natural and not entirely unexpected. It was reported that it would be helpful to see the Procurator Fiscal taking a firmer stand on such cases and not accept them.

It was indicated that a well written post mortem report should anticipate and answer most questions raised in practice but that the pathologists were happy to amplify it with follow up communication and correspondence as required. However, on the reverse side, nothing was received back by way of feedback to pathologists on cases and they had no way of knowing what the Fiscal was interpreting from the reports and what comments might be being imparted to relatives.

Only a small number of cases progressed to a formal Fatal Accident Inquiry and even then they could be 2 or 3 years later with the pathologist's role being simply one of presenting the evidence from the post mortem report. In comparison in England and Wales with frequent Coroner's inquests and shared and open inquiries the system was different and that in Scotland there was an awful lot of information from cases which never got fed back to the pathologist, clinician or anyone else which was unsatisfactory as a learning experience.

So far as suspicious deaths were concerned it was reported that there was some concern on the part of the pathologist about the relative junior status and lack of experience of Fiscals dealing with suspicious deaths. This frequently resulted in recourse to "rule books" rather than to common sense. Junior staff were not always aware of the protocols involved and sometimes contacted the pathologist unnecessarily early with unreasonable requests for attendance at briefings etc.

Concern was expressed at the number of people present at the homicide scene and later at the post mortem. This concern was largely based on the advances in modern scientific investigative methods especially DNA profiling and the risk, however small, of contamination.

Concerns were raised about formal identification by relatives at the mortuary prior to the start of the post mortem and the strict necessity for this, at least the apparent requirement that it be done formally to pathologists. To insist on this possibly within a short time of death was seen as heartless and in the case of someone who had spent some time in hospital and well-identified pointless. It was highlighted, however, that the protocols now do put evidence gathering above the requirement for formal identification. In the case of persons who have been injured or worse in the course of a crime it is of course particularly damaging to have to make the body presentable prior to the dissection taking place.

Doubts as to the necessity for a two doctor post mortem were also raised but it was appreciated that was a matter of law.

So far as retention of organs and tissues was concerned it was reported that procedures in respect of this had been tightened up considerably in recent years both to ensure that tissues were taken lawfully and that as appropriate they were returned to the body.

It was reported that in a substantial number of post mortem examinations (probably 50-60%) tissues would be retained at the end for further investigation, either small pieces of tissue (histology) for examination under the microscope and blood and urine samples for toxicology investigations. Notification of the retention of these was given to the Fiscal within 24 hours by means of faxing to the Fiscal a form giving basic details, cause of death, material retained and what investigations had been carried out. The histology tissues were processed in the University itself to form blocks and slides which would ultimately be permanently stored as part of the medical record.

In a small number of cases it was reported that in addition to the histology and toxicology a whole organ might require to be retained (invariably the brain). The practice nowadays in Glasgow was that this would be examined within a few days and returned to the body prior to release. As a result there was seldom any hold up in the body being released to relatives. Specific forms and special operating procedures were in place to ensure that the brain was not inadvertently retained instead of going back into the body and at all stages the Fiscal's Office would be kept informed by fax. These procedures were designed to comply fully with the requirements of the new Human Tissue (Scotland) Act.

So far as giving evidence in court was concerned, echoing other comments regarding feedback on post mortem examinations, it was reported that little if any feedback was given when it came to giving evidence in court. It was indicated that pathologists had no way of knowing if their evidence was presented as well as it could have been and that there had to be a lot of Police and scientific evidence brought out in the course of a trial which would be interesting to learn about in respect of the pathologist's own interpretation of injuries and events.

It was conceded that it was difficult to know just how such feedback might be provided but generally liaison between Crown Counsel and pathologists was virtually non-existent. This contrasted in his experience with defence advocates where the pathologist regularly discussed cases with them but sadly no such dialogue existed with the Crown. As a result he felt that the defence often had a far better understanding of complex pathology issues than the Crown and that banalities continued to be asked of pathologists in the witness box by Crown prosecutors and evidence continued to be presented in unimaginative and dated formats.

We recommend that the Department gives consideration as to how feedback can be given to Forensic Pathologists on the contents of post mortem reports and on the use of their evidence in court.

Views from Dr J Grieve, Senior Lecturer in Forensic Medicine, Pathology Department, The University of Aberdeen

Dr Grieve felt that the furore over the retention of organs had to be seen in the historical background of what pathologists were trained to do. In the past it was felt that retaining organs was the best way to examine them. In retrospect he thought it might have been better if the relatives had known, but the practice was based on improvement and learning. It was a benign position and doctors being attacked as monsters did not sit well with the reality of trying to protect relatives from distressing knowledge of what was regarded as an essential practice. There had been problems even prior to Alder Hey for example back in the 1980s there had been problems over the sale of blood products.

Dr Grieve believed that the new Scottish legislation in regard to Human Tissues was better than that in England following the McLean Report. It might be very difficult in England to retain any material but in Scotland the position, for example, regarding blocks and slides being part of the medical record was very useful.

So far as retention now was concerned when a Procurator Fiscal instructed a post mortem he thought that he or she could reasonably expect that the post mortem would include some standard items and it was good practice to take samples for histology purposes in all post mortems. He would not routinely report to the Procurator Fiscal the fact that he had taken these samples as they should be part of a normal post mortem which the Procurator Fiscal has authorised and instructed. Indeed the Royal College of Pathologists' Guidelines on doing post mortems required taking of histological material and it must be regarded as the professional body governing good practice. The Procurator Fiscal should rely on the fact that when he instructs a post mortem a competent pathologist is carrying out the dissection and following good professional practice. The Procurator Fiscal has to have confidence in the work of the pathologist.

He noted that other pathologists might inform the Procurator Fiscal about the taking of any samples including those for histology but he did not routinely do that. Organs were, of course, different and he would inform of the retention of an organ. He believed that "retention" in these circumstances meant retention of organs beyond the time of potential release of the body. He was asked how he was going to notify the Procurator Fiscal when finished with material which had been retained but did not yet have a working formal system for that.

In Aberdeen, to put this in some sort of historical context, the number of organs retained out of on an average of 550 post mortems prior to the problems would have been between 125 and 150, mostly brains. As he indicated before he thought it had been the right thing to do and indeed there could have been criticism if brains had not been retained. In comparison in the 12 month period from June 2005 to June 2006 only 3 brains were retained out of a total of 552 cases.

Now the usual practice was to retain the brain for a very short term and he did not think that there was much loss regarding findings as a result of short-term retention as opposed to longer-term retention. ⁴ In Aberdeen bodies were not necessarily released on the same day as the post mortem in any event as the toxicology result was always awaited where such investigation was performed before completing the death certificate.

If Dr Grieve had kept but expected to reunite material with a body prior to its release he would not routinely inform the nearest relative. He would of course give full information, if asked, but he would not pro-actively inform if he intended the material to be returned. He was always happy to explain to relatives when things had been kept for a little longer thereby inducing delay in release of the body and in his experience relatives were usually content with that.

On the few occasions when organs were retained he spoke to the relatives and told the Procurator Fiscal that he was doing so. He usually did this in the presence of a police officer and explained to them why he was keeping an organ and the likely length of time. These were invariably homicide cases and he indicated to them that he probably would have to retain it until after a High Court trial if there was one and even possibly until after any potential appeal.

At these meetings he would explain the three options regarding disposal to the relatives.

He indicated that one of the effects of the move to full disclosure was that pathologists were possibly telling people things that they would rather not know. However, that was the position.

When he did see relatives he tried to gauge their response and to accommodate any of their wishes. Some required more explanation and reassurance than others and it came down to human interaction and communication. If, for example, nearest relatives were violently against retention he would offer to speak to the Procurator Fiscal and at least explore the possibility of some options although he would indicate to the family that it might be inevitable. He would also particularly do that on the few occasions in practice where there were cultural or religious concerns. He would always do his best to accommodate people's wishes. He indicated that in comparison to the shock of losing someone, usually in violent circumstances, retention of an organ might be seen by some as a minor issue.

He thought it was good that he saw the nearest relatives. He was not saying that all pathologists need do that but it worked for him in Aberdeen. In one case he could not do so because the family was in England but he used the Police Family Liaison Officer to make the contact and that seemed to work well in practice. It was in his opinion a useful use of his time and he thought it was a matter of communication and consideration and was happy with what was being done. He felt it was necessary to be robust sometimes and explain the harsh realities to people.

One Procurator Fiscal Depute had said to him that it was important for him (the Depute) and others like him to learn more about this communication. He thought there might be a problem regarding communication and that role models were important. Teaching in a didactic fashion might not be the best option. Experience, however, was hard to teach.

When he was a junior doctor he said that they had been committed to doing post mortems in hospitals. They saw it as important in training and research. For example, in those days there would be approximately 1,000 adult post mortems a year in Aberdeen hospitals, now it was less than 100. The reasons were somewhat complex with a combination of influences. He thought public perception was important and had a big impact on authorisation. Various public "scandals" had impacted on people's willingness to authorise post mortems. Curiously as post-mortem numbers fell and medical students were less involved in post mortems as part of their teaching and training the issue tended to become self-perpetuating and they were less inclined to ask for something that was outwith their experience. The students now were not learning the same way as he had and, therefore, might have a different attitude. He thought it was a fallacy, however, to say that better diagnosis in life has reduced the need for post mortems. Things like MRI scans did help of course but they were no substitute for a full visual exposure following a dissection. He thought the drop in post mortems in hospitals was having an effect on teaching, training, audit and research.

Alder Hey of course had had a huge impact. The authorisation forms under the new legislation were probably too complex. It was well known that people took in very little information at times of stress and to get authorisation for a post mortem there was a very short window of opportunity to try and give people information and get them to think about it. You could not give them the information and ask them to come back in a week's time; it would be too late then. You also had to bear in mind he reported that some people simply could not read; pamphlets containing information might not be sufficient and individuals might need things explained verbally to them in greater detail.

So far as organ donation was concerned he stated that the transplantation teams always wanted more organs.

In Aberdeen there had been fewer donations from his caseload in the past couple of years, possibly linked to the retirement of the transplant surgeon in Aberdeen. Three or four years ago he might have seen five to seven cases a year where donation had taken place, usually in fatal traffic incidents, but not now. It had to be pointed out, however, that in Fiscal post mortem situations a very small number were going to be suitable for transplantation. Really only those persons who had been in hospital on a ventilator would be suitable. The exception to that was corneas. The window of opportunity for corneas was greater being up to 24 hours after death. He was happy in appropriate cases to accommodate requests for corneas for transplantation but it involved communication among the various parties. He had had a recent bad experience, for example, of agreeing to cornea donation where he had confirmed to the transplant team that he would take a blood sample (necessary for the transplant) but discovered that a blood sample had been taken prior to his dissection of the body, thereby impairing his ability to obtain samples for the Procurator Fiscal's purposes. This was a communication breakdown which showed how important co-operation and communication were.

Even potential donors in hospital might not be suitable especially if there had been an infection and again this left a very small number of suitable candidates. Given the small number of potential cases in the first place and the level of consent, the overall numbers of cases that he dealt with who might have been potential organ donors was very small.

So far as the pathologist being present at the time the organs were taken for transplant was concerned he did not think that was appropriate. It would not be useful for him to be present when the transplant team took the organ in question but it was essential that the transplant surgeons took a responsible attitude at the time of harvest and adequately documented their procedures and the condition of organs and tissues which they had disturbed.

Having said all that, however, he would endeavour to accommodate relatives' wishes for donation.

Overall, his comment was that communication and co-operation were the answer. Handling death cases was not a competition amongst the various agencies involved, it was a team activity and discussion might be necessary, even robust discussion.

He felt a national forum for Forensic Pathologists was needed. There were only about 8 or 9 Forensic Pathologists in Scotland and such a forum could be a useful platform for discussing good practice and talking about things in an open and robust fashion. He thought the Crown Office would probably be best placed to arrange and host these events. For example, there had been a recent discussion on how drugs deaths were treated involving representatives from all 4 major Scottish centres, facilitating exchange of information regarding practices and allowing participants to consider in a non-contentious, non-dictatorial and non-recriminatory way how they might modify their own practices. The forum would be useful for discussion of matters of common concern.

So far as feedback on his cases was concerned he did not see it as a problem in Aberdeen as he regularly had inter-agency discussions and of course the forum he recommended would also be very useful for feedback on the quality and usefulness of post mortem reports and on the effectiveness of evidence given in court by pathologists.

He did agree that the whole business of the Procurator Fiscal's role at the scene of a murder and at the post mortem needed review and needed to be argued robustly by all the participant parties. People needed to understand each other's roles and functions and again the forum might be a useful platform for discussion of matters such as this.

Finally, in the spirit of the new legislation he did not think that certain categories of death should necessarily lead to post mortem examinations, for example maternal deaths. A woman might well suffer a cerebral haemorrhage, for example, during pregnancy, well documented by investigations prior to death. It would be inappropriate, in his opinion, to subject her to a mandatory, Procurator Fiscal instructed, post mortem simply because she was pregnant when the cause of the death was well known prior to it taking place. He would, nonetheless, encourage enquiry into maternal deaths and would enthusiastically urge that permission for autopsy was sought in any maternal death (under the terms of the Human Tissues Act) but not using the Procurator Fiscal unless the circumstances otherwise would require the death to be reported.

He did agree with some of the views expressed elsewhere regarding some deaths which were overtly natural and explainable being unnecessarily reported to the Procurator Fiscal. Again that was something that could be discussed at the forum he previously recommended and might be further debated through the forum with appropriate Medical Royal Colleges.

In view of the above we recommend that:

The Crown Office host a forum for Forensic Pathologists where issues of mutual interest could be discussed.

We are grateful to the large number of contributors to this chapter who freely gave of their time and experience. We return to the issues in Chapter 9.