Of the patients autopsied, NCEPOD received reports, complete or partial, on 59% (85/144)
and it was not possible to identify the source of one. Table 79 shows that 90% (76/84) were
ordered by a coroner and 10% (8/84) followed consent from relatives.
Table 79. Source of autopsy reports received
All the reports of consented autopsies contained a clinical history, whilst 86% (65/76) of the
coronial reports did so. These were graded as satisfactory or good in 74% (54/73) and all
the 18 unsatisfactory reports were in coronial cases.
One third of the unsatisfactory cases were so categorised because they failed to mention
the pre-mortem endoscopy procedure or the insertion of a PEG feeding tube (even in
cases where it was also mentioned in the external description). Failure to note important
documented peri-mortem infections such as MRSA and Clostridium difficile were also
unsatisfactory. The remaining unsatisfactory histories were telegraphic and too brief.
The absence of a clinical history in autopsy reports is a long-running complaint in NCEPOD
reports, particularly in coronial autopsy reports. In 2001, a similar proportion also had no
such history. It is counter to established and more recent autopsy reporting guidelines, but
the pathologists are not helped by an instruction given by many coroners to omit clinical
histories from reports. One reason given is that the pathologist may easily make a simple
factual transcription or interpretation error such as the date of an operation. This can lead
relatives, if they are seeking substance for a complaint against a hospital or clinician, to
cast doubt on the rest of the report and raise further and often irrelevant issues. Relatives
are increasingly receiving and studying autopsy reports, and so the issue of how much
detail to include about what may have been a very complicated clinical situation requires