Pathology - Post Mortem Examinations

Summary

The Northern Care Alliance NHS Foundation Trust is an organisation that believes the care of its patients and staff is paramount. In support of this belief, we are providing this information leaflet to help you make an important decision.

We hope to offer you support, care and information in a compassionate and sensitive manner. If there is any part of this leaflet that you do not understand or doesn’t appear clear to you, then please do not hesitate to ask any member of the bereavement or mortuary staff.

Post-mortem examinations provide valuable information on the cause of death and can provide vital information for future treatment and research.

There are two types of post-mortem:

1. Post-mortem examinations required by HM coroner. These are investigations required by law at the instruction of the coroner.
2. Consented post-mortems, which are requested by doctors or by relatives. You as relatives must give a fully signed agreement before we can carry out this type of post-mortem. You can make conditions about what we do, and we must make sure that you are fully informed before you give your consent.

You will be given time to consult your family and will have the option to change your mind, although, usually this must be done within 24 hours of giving consent.

The post-mortem examination

Introduction

This guide aims to give you practical information about the post- mortem examination. A post-mortem examination may help doctors improve their treatment of future patients. Also, there may be information available from the examination which may be relevant to the health of family members in the future. There is a glossary of words used at the back of this leaflet to assist you, but please ask the person who gave you this if there is something you are unclear about or would like explained in more detail.

It is important that you feel that you have enough information before making a decision about whether to agree to a post- mortem examination or to the keeping of tissues or organs.

The benefits of a post-mortem examination

A post-mortem examination can give valuable information about an illness and its effects on the body and may give a fuller explanation as to why your relative died. This information may make it easier for you and other family members to come to terms with the death.

Post-mortem examinations can also provide valuable information, which can help doctors to treat other patients with the same kind of illness and can provide vital information for research.

Types of post-mortem examination

There are two types of post-mortem examination.

The first is the coroner’s post-mortem, which applies in England, Wales and Northern Ireland. When a post-mortem examination is requested by HM coroner, the formal consent of the relatives is not required. In the United Kingdom, most post- mortem examinations are required by the coroner.

It is performed to investigate:

 

• Sudden and unexpected deaths
• Deaths where the cause is unknown and the doctor cannot issue a death certificate
• Death where the cause of death is known to be, or suspected to be, due to causes other than natural disease (e.g. accidents and industrial diseases)

The second type of post-mortem examination is the consented post-mortem, which is done usually at the request of the doctors who have been caring for your relative. Sometimes close relatives wish to find out more about how a person in their family died.

This type of post-mortem can be done only with your written consent.

Coroner’s post-mortem examination

The coroner is an independent officer with statutory responsibility for the legal investigation of some categories of deaths. The doctors who have been looking after your relative must discuss the case with the coroner if the death has occurred under certain circumstances (e.g. if death is known or suspected to be due to an accident or industrial disease). If the coroner decides that a post-mortem is required, the pathologist will be asked to carry this out and report the findings to the coroner.

In these circumstances, the pathologist acts for the coroner and is independent of a hospital. Your agreement is not required. The coroner will subsequently issue the medical certificate and their officer will get in touch with you to let you know when to proceed with the funeral arrangements. Alternatively, your chosen funeral director will liaise with the coroner’s officer on your behalf.

If an inquest is required, it will be opened and then adjourned to allow the funeral to take place. The inquest will be held several weeks later when all the results from the post-mortem examination are available.

If a coroner’s post mortem is required, the next of kin will be contacted by the coroner’s officer. The staff at the coroner’s office are very helpful and will answer any questions you may have. You will need to contact them as soon as possible in order to discuss details relating to you relative/friend.

For Salford residents the address is:

HM Coroner for the County of Greater Manchester West District, Coroner’s Court, Paderborn House, Civic Centre, Howell Croft North, Bolton, BL1 1JW
Telephone: 01204 338 799 / Fax: 01204 338 798
The office hours are: 8.30am - 4.00pm (closed 12.30pm - 1.30pm for lunch).

For Rochdale, Bury and Oldham residents the address is:

HM Coroner for the County of Greater Manchester North District, HM Coroners Office, Floors 2 and 3, Newgate House, Newgate, Rochdale OL16 1AT.
Tel 01706 924815 / Fax: 0844 963 2383
The office hours are Monday to Friday 8.30am - 12.30pm and 1.30pm - 4.30pm.

Consented post-mortem examination

If a coroner’s post-mortem examination is not required, the doctors may ask you to agree to a post-mortem examination of your relative. This may help the doctors to give you, if you wish, more detailed information about why your relative died and may also contribute to the development of new ways of treating future patients with similar problems.
 
If you agree to a consented post-mortem examination, the doctors will issue the medical certificate of death before the post- mortem so that you can proceed with the arrangements for the funeral.

Consented post-mortem examinations can be:

Full

This involves a detailed examination of all the internal organs including the brain, heart, lungs, liver, kidneys, intestines, blood vessels and small glands, which are removed from the body, examined in detail and then returned to the body.

Limited

You may be uncomfortable with the idea of a full post-mortem examination. If this is the case, you may be asked to consider agreeing to a limited post-mortem examination. This could involve examination of only those organs directly involved in your relative’s illness, e.g. if someone has died of a stroke then only the brain and blood vessels supplying the brain may be examined.

It is important to remember that the pathologist will only examine organs and/or small pieces of tissue, which have already been agreed between you and the doctor who was looking after your relative.

This may, however, mean that no information will be available about possible abnormalities present in other organs, but which may have contributed to the death of your relative.

What is a post-mortem examination?

A post-mortem examination is the final step in the investigation of your relative’s illness. It is a careful internal examination of the person who has just died and can give valuable information about an illness and its effects on the body. It may tell us more precisely why your relative died.
 
Post-mortem examinations are carried out by a pathologist, who is a doctor specialising in the laboratory study of disease and of diseased tissue, assisted by a technician who is a person with specialist training to assist pathologists. They are carried out in special facilities provided in the hospital which resemble an operating theatre and provide respectful storage of the deceased.

Pathologists perform post-mortem examinations to standards set by the Royal College of Pathologists. These standards include carrying out the examinations in a respectful manner and with regard for the feelings of bereaved relatives.

After making a careful external examination of the body, the pathologist will remove and carefully examine all of the major internal organs, such as heart, lungs, liver, kidneys and brain.

After the examination the organs are returned to the body (it is not possible to replace them exactly in their original positions) and the body will be carefully prepared so that the family may view the body before the funeral if they wish.

In many cases, the pathologist can identify diseases by naked eye, but in some cases findings must be confirmed. In these cases small tissue samples, similar to biopsies taken in life may be kept for further investigations with a microscope.

This tissue is processed into wax blocks in a specialised laboratory. Very thin sections or slices are then taken which are stained for examination under the microscope.

Occasionally the blocks may need to be slightly larger, particularly in cases involving diseases of the brain.

The laboratory processing may take several days. The post mortem examination is complete when the microscope examination is finished and a report will be prepared. The blocks and microscope slides which are produced can be kept as part of the medical record, with your consent, in the same way as biopsies performed during life.

We would advise that there are benefits to keeping the tissue in this way, for medical education, laboratory quality checks and potentially for the benefit of future generations of your family.

In coroners examinations the pathologist is required to make microscope examinations if necessary. In consented examinations you could limit the post mortem examination not to include microscope examination, but the pathologist may then advise that there is no benefit in a naked eye examination.

You will need to decide what should happen to any blocks and slides which are produced. You may decide for the pathologist to keep the tissue as part of the medical record. You may ask for the tissue to be returned to the body, in which case we will advise you if that would result in a delay to your arrangements. You may ask us to dispose of the tissue by legal and appropriate means or we can return the material to you (usually via your funeral director) so that you can arrange it’s disposal.

If the tissue is disposed of it will not be possible to perform any further examination in the future.

On rare occasions detailed laboratory investigations may require particular organs to be kept for some time. In coroner’s examinations this may be necessary, but the need will be discussed with you by the coroner’s officers. In consented post mortems when there are reasons to retain an organ you will be asked to give your written agreement.

The form you sign must indicate whether you agree to any organs being kept, and, if so, for what purpose and how you wish them to be dealt with when their examination is complete with the same choices as for tissue.

Some of your questions answered...

When will the post-mortem be carried out?

The initial post-mortem examination is carried out as soon as possible after death, usually within two or three working days. You will be given time to discuss the request to carry out a post- mortem examination. When religious observance requires a funeral within 24 hours, every effort is made to carry out the post-mortem within that period.

Will a post-mortem delay the funeral?

Your relative’s body is usually released to the undertaker a short time after the post-mortem or at HM coroners instruction. In the case of a consented post-mortem, the body can be released when the death has been registered and the relevant cremation certificate is complete (if applicable). In the case of a neurological specific examination which requires the “fixing” of the brain, then the body would be released to the undertaker in the usual way, but the brain could be retained for approximately 6 weeks. You may wish to proceed with funeral arrangements or wait to reunite the brain/organ with the body. You will need to discuss your wishes with the undertaker.

Will the body be disfigured?

After the post-mortem the technician will take great care to reconstruct your relatives body to a very high standard and will prepare your relative’s body for you to see again, should you wish. The internal examination involves an incision down the front of the body, which cannot be seen when your relative is dressed. If the brain has been examined there will also be an incision concealed in the hair at the back of the head.

Do relatives have to give their agreement to the post-mortem examination?

Unless the post-mortem is directed by law at the request of HM coroner, your consent must be obtained before any investigations are carried out. Relatives do not have to give their agreement unless they wish to. You should only give your agreement after you have had the purpose of the post-mortem examination explained to you and you have had sufficient opportunity to ask questions before reaching a decision. You may need time to consider whether to give your agreement and to talk to other family members.

Why do we ask if we can keep some organs?

You may prefer to agree to the pathologist carrying out the post- mortem and keeping what is considered necessary without going into specific details.

When a post-mortem examination is first discussed with you, you may be asked whether the pathologist can keep a specific organ such as the brain, to enable medical staff to carry out a more detailed examination. The organ, would be kept in safe and secure conditions in compliance with Human Tissue Authority Regulations within the hospital. The identity of the organ and the diagnosis would be confidential and treated in the same confidential manner as all medical records.

At times the doctors would like to keep the organ for a longer period. This is because the long-term availability of the organ provides an opportunity to learn important information about the underlying condition and its treatment both now and in the future. If you agree to an organ being kept, you will be asked to confirm your agreement in writing.

If in the future you change your mind, we can, in consultation with you, respectfully dispose of the organ or return it to you for cremation or burial as you may wish.
 
The reasons why the pathologists may wish to keep an organ or tissue should be explained to you.

These reasons may include:

• To determine cause of death
• Specific research
• Keeping for future research
• For the education and training of medical students and doctors
• Discussions between other clinicians and pathologists

You may:

• Wish to ask about the implications for agreeing to these uses
• Like to ask whether tissue or organs will be used for genetic research
• Wish to know whether you are likely to be involved in any extra expenses

If you consent to an organ being retained for these purposes, it may not be necessary to keep all of the tissue indefinitely for teaching and research and the tissue may be disposed of in an appropriate manner in the future. You should indicate if you would wish to be informed or consulted at that stage.

If you do not wish us to keep an organ, you may be asked whether you would allow us to keep it for several weeks so that the pathologist and other doctors can examine it in detail before issuing the post-mortem report. We can then respectfully dispose of the organ or return it to you for cremation or burial as you wish.

It is important that, if you do not wish us to retain an organ or any organs at all, you inform us when permission to carry out a post-mortem examination is discussed with you. It is important that you record on a specially prepared consent form what you agree to. You will be given copies of any consent forms to keep.

Will the relatives be able to find out the results of the post- mortem examination?

A report on the post-mortem examination will automatically be sent to the consultant who looked after your relative or to the coroner in the case of a post-mortem requested by the coroner. A report may also be sent to your relative’s general practitioner at their request. As these reports are usually written in medical terminology, it may be helpful to have the results explained to you. You can ask for an appointment with the consultant who had looked after your relative, with your relative’s GP or with the pathologist who carried out the post-mortem examination. They can then discuss the results with you.

What if I have other questions?

You may have other questions. The doctor who discusses the consent may be able to answer them but you may have questions which arise later, possibly after discussions within the family.

Please contact the bereavement office on 0161 206 5174 or 5175. They will be able to contact a member of the pathology staff who will be able to answer your questions.

Glossary of terms

Archiving

Archiving is the long-term preservation of tissue or organs. Archives are important and useful because:

• The preserved tissue or organ can be re-examined if new diagnostic techniques or fresh knowledge about disease might give a clearer explanation of the deceased’s illness
• The education and training of medical students and doctors is helped if they can see for themselves what happens inside the body in disease
• Research using archived tissues and organs can help in the diagnosis and treatment of future patients

Consented post-mortem examination

Post-mortem examinations performed with the agreement of relatives are called consented post-mortem examinations.

Coroner

The coroner is required by law to investigate deaths due to unnatural, suspicious or unknown causes. In some cases, the coroner may hold an inquest. The coroner is assisted by coroner’s officers.

Coroner’s post-mortem examination

Most post-mortem examinations in the UK are performed at the request of coroners. The agreement of relatives is not required. Attendance at an inquest is necessary in only a minority of cases.

Fixing

Before organs or tissues can be examined in detail, particularly with a microscope, they have to be hardened by immersion in a chemical, usually formaldehyde. This is known as fixing. The complete process may take several weeks, for example brain tissue will need longer for 'fixing'.

Full post-mortem examination

The full post-mortem examination involves examination of all of the contents of the chest and abdomen and also the brain.

Inquest

Inquests are held by coroners when death is known or suspected to be due to anything other than natural causes. Sometimes they are held in the presence of a jury. The purpose is to consider all the evidence relevant to the death and to give relatives, or their legal representative, an opportunity to question witnesses.

Incision

An incision is a cut in the skin, enabling the body to be opened. The incision is made in the same way as for a surgical operation. The incision is closed at the end of the post-mortem examination.

Limited post-mortem examination

A post-mortem can be limited in consented post-mortem examinations and if relatives so wish, to one body cavity (eg. the head, abdomen or chest). This may not provide all possible information about the cause of death.

Medical Certificate of Death (Death Certificate)

The death certificate is a document required by law. It enables the Registrar of Deaths to issue a form permitting disposal of the body. It also gives the cause of death; this is important for recording the incidence of diseases in the UK, but research has shown that up to 30% of the information on a death certificate may be wrong unless it is based on findings from a post-mortem examination. The cause of death written on the certificate can be changed later when the results of a post-mortem examination are available.

Mortuary

The mortuary is a group of rooms usually in a hospital where bodies are kept in refrigerators before collection by undertakers. The mortuary also includes the post-mortem room where the post-mortem examination is performed.

Organs

The body contains many organs such as the brain, heart, kidneys, lungs and liver. Each organ carries out different functions. The organs are connected in the body by nerves and blood vessels.

Pathologist

A pathologist is a medical doctor trained in the diagnosis and study of disease. Pathologists who perform post-mortem examinations usually work in hospitals and are involved in the diagnosis of disease in patients; these pathologists are called histopathologists. Pathologists work to standards laid down by the Royal College of Pathologists.

Tissue

Organs contain tissue, collections of cells which give organs their special functions, e.g. the heart contains muscle tissue composed of cells which contract to pump the blood. Samples of tissue (typically small slices about 3mm thick) are usually taken during a post-mortem examination for examination with a microscope; this involves treating the tissue with chemicals and embedding it in wax; this wax embedded tissue is then kept safely and securely so that it can be re-examined later if necessary.

Technician

A technician is a person, with special training to assist pathologists in the diagnosis of disease. Technicians help the pathologist carry out the post-mortem examination and prepare any tissue that has been kept for study with a microscope