Her Majesty’s Coroners have been in existence since being empowered by Richard the Lionheart in the late 12th century. After Richard was ransomed from the German robber barons along the Danube, the royal purse was bankrupt. The Crown had to raise funds, but the Sheriffs controlled the flow of taxes in each county at that time. The ‘General Eyre’ (an early royal court) of September 1194 was held in the County of Kent, and Article 20 boldly stated, “In every county of the King’s realm shall be elected three knights (Coroners) and one clerk, to keep the pleas of the crown.”

This was the statutory basis for the post of Coroner. For 20 years or so, the Coroners and the Sheriffs battled for the

legal right to prosecute the law and keep the proceeds. Individuals appointed to the post of Coroner originally had to be knights, and they had to possess an annual income of at least ￡20 per year. The hope was that well-to-do men would not embezzle and steal from the Crown in the way that Sheriffs did. Twenty years later, one of the main statutes of the Magna Carta stated that neither Coroners nor Sheriffs should hold the Pleas of the Crown.

The duties of medieval Coroners were:

• to service the Royal Courts of Law (the General Eyre)

• to investigate all aspects of life and crime, including murder and manslaughter

• to keep records of the proceedings on Coroners’ Rolls

• to inspect a corpse (this legal duty existed until 1980).

Formal medical input into the investigation of deaths started in 1836, when the Coroner was officially allowed to pay a fee to a medical witness. These enquiries were often carried out by police surgeons, whose main duty was the inspection and recording of injuries and the investigation of rape.

In 2013, approximately 230,000 (45%) of all registered deaths in England and Wales were reported to a Coroner. Over 94,000 of these (41%) underwent a Coroner’s autopsy, with around 30,000 (13%) resulting in a Coroner’s inquest. Since the mid-1990s, the proportion of deaths reported to the Coroner that are investigated by autopsy has fallen by a third (from 61% to 41%), although that reduction bottomed out at the start of this decade and shows no sign of further reduction. The proportion of all inquests that involve an autopsy has fallen from 98% to 84%, however the number of

autopsies performed that went to inquest has actually risen by around 15%. This service requirement is not going away.

In 2015, the Coronial autopsy service in England and Wales is provided in hospital or public mortuaries, usually by histopathologists primarily employed by the NHS, who nevertheless answer to the Coroner in these cases. Remuneration has been mostly static for over a decade, and the financial arrangements by which pathologists are (or are not) paid are as diverse as the ways in which the work is accounted for in their job plans. In some areas, for example central London, many Coroner’s autopsies are carried out by forensic pathology consortia. Attendance at court almost always occurs during the working day and thus impacts on the delivery of care to patients by pathologists and other healthcare staff who are called as witnesses. Incidentally, a Coroner is entitled to fine or jail any individual (￡1000 or up to 28 days respectively) for contempt of court, which would include nonattendance when summoned to an inquest.

In 2010, the histopathology curriculum was changed to make autopsy training optional in stages C and D of the programme. This followed a decade of debate and calls from many quarters for autopsy-free training. As Director of Training at that time, I argued against the change, believing then – as I do now – that autopsy training isn’t just about training to do autopsies. It is my belief that autopsies are the best way to appreciate systemic pathology and the effects that diseases have on the rest of the body. Histopathology trainees are still required to undertake autopsy training until the end of stage B, and questions about autopsy practice and pathology are still included in the Year 1 objective structured practical examination (OSPE) and Part 1 FRCPath examination. After Part 1, trainees may opt out of autopsies and their programme is consequently shortened by three months.

The College has previously received information regarding regions or hospitals that have struggled to provide a Coroner’s autopsy service. Reasons given included the poor level of remuneration, conflicts with Coroners over the ability of the pathologist to adequately investigate deaths, the impact of the Human Tissue Act and the introduction of optional autopsy training as described above. The latest of these communications was a letter from a senior

Coroner in England, documenting the collapse of the autopsy service across the county that he serves. We decided that the time had come to consult the College Fellowship and collect as much data as possible to provide a definitive picture of the Coronial autopsy service in England and Wales in 2015. A SurveyMonkey questionnaire was circulated to all histopathology Fellows and all stage C and D histopathology trainees on 22 June 2015. To date, we have received 533 responses, the second highest number of responses recorded by a College-created survey. The survey remains open, should readers wish to undertake it. It takes just a few minutes to complete.

Key survey results

• 463 consultants and 70 trainees have taken the survey.
• All English regions, Wales, Scotland and Northern Ireland were represented.

Consultants

• 95% took the autopsy exam as an integral part of the FRCPath.
• 71% undertake Coroner’s autopsies.
• The number of autopsies undertaken annually varies from 2 to over 800 per year. Respondents were asked to describe how they are paid for autopsy work: 86% of those responding are paid directly by the Coroner the majority of these have non-NHS time in their job plan and reported ‘time-shifting’ anything from 50–100% of the time taken to perform autopsies.
• 13% are paid as part of their NHS programmed activities (PAs) or university contract via an service level agreement between the Coroner and their employer
• two respondents stated that the fees for their autopsies go to their employing NHS trust or university.

With respect to training:

• 79% supervise trainees undertaking Coroner’s autopsies
• the majority of those who don’t simply have no trainees
• five respondents cited lack of time and NHS work pressures as the reasons for not supervising trainees.

In terms of future intentions:

• 26% intend to give up Coroner’s autopsy work in the near future
• a quarter of those answered the subsequent question as to why

When asked if their hospital department or public mortuary had struggled to provide a service in this context, 52% answered in the affirmative. The measures taken to bolster the service are shown in Table 3. Of the 29% of consultants who do not undertake Coroner’s autopsies, 92% had done at some time in the past. Of the 27% of consultants who had given up autopsy work having previously undertaken it, we asked whether anything would prompt them to consider restarting. We asked consultants who had given up whether they would restart autopsies if they were included in and paid for by NHS PAs, either within current PAs or as additional PAs. Over 80% of respondents said they would answer ‘no’ to either question.

Trainees

• 70% of all trainees continued with autopsy training in stages C and D
• 33% of these did the old-style autopsy exam
• 25% have passed the certificate of higher autopsy training (CHAT)
• a further 30% intend to sit the CHAT before taking a consultant post.

89% of trainees undertaking higher autopsy training intend to undertake Coroner’s autopsies in a consultant post, if required. Four trainees who are autopsy-trained gave information about why they do not intend to practice as a consultant. One decided to focus on molecular pathology, stating that there wasn’t time to do everything. A second stated that NHS workload pressure meant that autopsies couldn’t be done to a high enough standard. A third is in Scotland, and a fourth blamed poor remuneration and a lack of interest in the subject.

The main reasons given for not continuing in higher autopsy training were personal preference and the poor quality of autopsy training in their region. 55% of those who did not train said that they would consider undertaking the CHAT later in their career. When asked what might persuade trainees to undertake autopsy work, the most popular answer was increased remuneration.

Conclusions and commentary

The survey gave some unexpected and very interesting results. The proportion of consultants undertaking autopsies for example was unexpectedly high compared to previous estimates of less than 50%. However, the respondents are likely to be a self-selecting population; if you don’t do autopsies, you are less likely to be interested enough to take the survey.

It is clear that whilst the introduction of optional higher autopsy training will not help to increase the overall number of trained autopsy pathologists, established consultants giving up is a much larger problem. The survey supports anecdotal evidence from regional training leads via Annual Review of Competence Progression (ARCP) panels that around two-thirds to three-quarters of trainees continue to undertake higher autopsy training and that around 65% of trainees overall intend to undertake Coroner’s autopsies as consultants.

The reasons given by consultants who had either given up autopsies or were considering giving up were no great surprise; poor remuneration, lack of time and NHS workload pressure, the impact of the Human Tissue Act on their ability to examine tissues or retain organs and impending retirement are all issues that have been raised in previous communications.

Of greater concern were suggestions that the quality of the work of Coroners’ officers was falling, and that poor-quality police investigation placed pathologists in compromising positions that threatened their professional reputation. The survey prompted several respondents to send the author emails outside of the survey that detailed cases of bullying behavior by police who had inadequately investigated suspicious deaths and who subsequently

tried to accuse the pathologist of negligence or unprofessional behaviour when the true circumstances came to light. In addition, there is anecdotal evidence that GPs allegedly feel increasingly bullied by Coroners and their officers to provide causes of death in cases where they have little or no information about the last days or weeks of a person’s life.

The proportion of departments struggling to provide the service is also greater than expected, but more worrying is the number that have failed to address the problem in any way. Combine that with the proportion of pathologists who have either given up autopsy practice or who intend to in the near future and one comes to appreciate that this is an already hard-pressed service on the edge of a complete meltdown.

The Hutton Review of forensic pathology in England and Wales was completed in March 2015, but was embargoed during the general election. It is likely to be officially published soon, but the author has seen a copy of the report that has been submitted to the Minister of State for Crime Prevention.

The review was extended to include the Coronial pathology service. Its main conclusion is that, although the forensic service is functioning satisfactorily at present, the future for forensic and non-forensic pathology services is “fragile, and corrective action needs to be taken now”.

High-quality death certification is essential for the development of effective healthcare policies. If you don’t know for sure why patients are dying, how can you hope to properly plan and manage healthcare systems for the living? Hutton supports this view in the covering letter to his review. He states “It is for the Government to take its own view on this

issue after considering my report. If, as I hope they would, they decide that recording accurate death causation (with the proper certification) is indeed an important metric for the public interest, then action needs to be taken in the immediate future.”

This College has previously communicated its concerns about the Coronial autopsy service to the Ministry of Justice, the Department of Health and other relevant parties, but no action has been taken to date. A concerted strategy of political and public engagement is necessary to communicate the need for urgent action to prevent a complete collapse

of the service, with all the associated problems for relatives and the public in general.