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6 July 2014

Please also read my disclaimer

Please note: This post contains information about a detailed internal examination which may upset some readers. 

Post Mortem Examination

What is a post mortem examination and what happens at a post mortem?

(please also see below for different type of post mortems)

A post mortem examination, also called autopsy, is an internal examination of all the major organs. They are performed by specially trained medical professionals called pathologists. A big misconception is that the post mortem is performed by the Coroner. In fact, the Coroner is the legal person who sits in court and makes all the decisions. The Coroner asks a pathologist of his choice to perform a post mortem. We have certain approved pathologists which we use routinely. Some of them are independent, some of them are attached to hospitals. (of course, it may have been so in the past that the Coroner and the pathologist are one and the same person, and maybe there are still parts in the world where this is true? I don't know of any such arrangements anywhere in England though!)

Some pathologists may have their own little ways of working, but the majority of the post mortems I viewed were done as follows :

A 'Y' incision is done starting below the shoulders and going down all the way to the groin. The major internal organs are taken out. The head is cut open behind the ears (stretching from one ear to the other behind the head by the hairline) and the brain is removed. The pathologist than examines the internal organs outside the body. Afterwards, the internal organs are placed back in the body and the body is closed.

Sometimes it is necessary to take histology if a cause of death cannot be established by simply looking with the naked eye. This involves taking small tissue samples (almost like a biopsy) which will be preserved, pressed into slides and looked at under the microscope. Also, in some cases toxicology is done. This involves taken  either blood, urine and/ or ocular fluid (the fluid around the eye) to see if alcohol and drugs (prescribed or illicit) are in the system. This is not done routinely, but only if the history of the case suggests that drugs and/or alcohol could have played a part in the death, if the cause of death otherwise cannot be established or if the Coroner requires it for an investigation (i.e. in a road traffic death to establish if the deceased person had consumed alcohol).

Please note that some of that work will be done by the APT (= Anatomical Pathology Technician). They are, in my opinion, the true heroes of the mortuary. They will also 'restore' the body after the post mortem: sew up, clean blood up, wash the hair).

In the Coroner's office, we do deal with 3 (only very slightly) different post mortem examinations:

1. Coroner's Post mortem
2. Forensic Post mortem
3. Hospital Post mortem

1. Coroner's Post Mortem

They majority of all the post mortems we do deal with. Ordered by the Coroner, their purpose is to establish the cause of death. The Coroner is not allowed to carry out further research on the body once a cause of death has been found. Histology and/or toxicology are not taken routinely.

2. Forensic Post Mortem

This is done in suspicious deaths and the Police will ask the Coroner to authorise a Forensic Post Mortem (and pay for it!). The main difference is that it is much more detailed than a Coroner's Post Mortem i.e. every inch of the skin will be looked at. Police Detectives and Forensic Photographers will be present to take evidence or a potential prosecution. Histology and toxicology are taken routinely. Those post mortems are performed by specially trained pathologists (forensic pathologist).

3. Hospital Post mortem

I mention this for completeness sake. The Coroner has nothing to do with a hospital post mortem, does not order hospital post mortems and we won't know the results if such examination has taken place. In cases of hospital deaths where there is no Coroner's post mortem required, the hospital doctors sometimes ask the family if they would agree to a hospital post mortem. This will need the permission from the family - unlike a Coroner's post mortem. 

Can a family refuse a post mortem?

Yes and no. Sorry, it's not so straightforward..

The Coroner's Office has a duty to inform the family where and when a post mortem will take place and they are entitled to have a medical representative present should they wish to. 

Legally speaking, if a family want to stop a Coroner's post mortem, they would need to go to the High Court to do this, and the High Court would need to be prepared to potentially issue a death certificate. Of course, this could be a lengthy legal procedure, and will delay matters for the family. The body will not be released until a cause of death has been established.

The Coroner does not need a family's permission to carry out a post mortem, but of course if a family have strong objections, we try to communicate with them to resolve issues. Quite often, refusal is on religious grounds. There is the possibility of a 'non-invasive' post mortem via CT scanning, but unfortunately, we cannot do this and family would have to arrange it themselves (quite often via a religious organisation). However, if the CT scan does not establish a cause of death, a post mortem would still need to go ahead. Again, potentially lengthy delays. Another possibility we offer is a restricted post mortem where the Coroner's pathologist does an internal examination as described above, but will stop when he has found a cause of death. For example, the heart gets examined and a degree of heart disease is found indicating a cause of death, than the head does not need to be opened to have the brain examined.

Post mortem report

The family and all other 'interested person's are entitled to have a copy of the post mortem report. We don't send them out to families routinely, as it is obviously not a very nice post to receive, but only when asked for them. They are usually not very easy to read and peppered with medical terminology. We advice families to see their general physician to have the terminology explained  It is purely a report which outlines the pathologists examinations - how did the organs look like, any blocked arteries etc, toxicology if done, weight of the organs - and the medical cause of death. It will not contain details about the events surrounding the death or speculate on the circumstances of the death. 

Peggy x