The Annual Coroners Statistics for 2017 that have been published this month, may not be top of the reading list for many inquest practitioners, however they are always worth a summary glance, as the figures reflect the huge volume of work that Coroners deal with behind the scenes that is often not appreciated when there are more headline grabbing inquests or judicial review cases to be reported.
The key trends (which it is well worth knowing about) are summarised here, along with important, new information about research demonstrating the reliability of non-invasive post mortem examinations by enhanced CT scanning (PMCT) and why greater use of that modality is strongly to be encouraged.
Summary of the Annual Report
There were 229,700 deaths reported to Coroners last year. However, the annual number crunching reveals only two notable year on year changes once the impact of DOLS deaths is taken into account: first, a welcome reduction in deaths of those detained under the Mental Health Act and second, a massive increase in the number of non-invasive post mortem examinations conducted.
Key figures
- 11% fewer deaths reported
- 18% fewer inquests opened
- 22% reduction in mental health deaths
- 120% increase in non-invasive post-mortem examinations.
Key facts
Changes in legislation have led to fewer inquests: The 229,700 deaths reported to Coroners last year were 11% fewer than in 2016. However most of this reduction is attributable to changes in the law regarding ‘DOLS’ deaths. In 2016 deaths of those who were subject to a ‘Deprivation of Liberty Safeguards’ (or DOLS) authorisation under the Mental Capacity Act were considered as deaths ‘otherwise in state detention’. That meant that each such death mandated an inquest even where it was clear from the outset that the death was from natural causes. Consequently, thousands of unnecessary inquests were being held until the revision to the coronial legislation came into force on 3 April 2017. The effect of the welcome changes to CJA 2009 is an overall 18% drop in the number of inquests compared to 2016, with 31,500 inquests opened in England and Wales during the year.
Fewer people are dying in state detention: DOLS deaths aside, one of the notable changes is the significant reduction in deaths in state detention, that is mainly deaths of those detained in prison, immigration centres, police cells or under a provision of the Mental Health Act 1983 (‘the MHA’). There were 528 such deaths in 2017, 46 fewer than in 2016. This is a statistical and not an anlaytical report. Therefore, though we can see that the change is mostly accounted for by a 22% reduction in deaths of those held under the MHA, we do not know the reasons behind the reduction. Furthermore, these statistics do not reveal how many of the 196 people who died in psychiatric detention in 2017 died at their own hand or due to the actions or inactions of others, rather than from natural causes or in accidents.
Key debate: With Pathology services under pressure is it time to further increase the use of PMCT?
The other key change – not highlighted in the 2017 “main points” executive summary – is the 120% increase in the use of non-invasive PM techniques.
Coroners ordered 85,600 post mortem examinations in 2017, comprising 37% of all reported deaths. But in just under 62,000 of post-mortem cases, no inquest was required. This suggests that the large majority of these post mortem examinations led to a natural cause of death being identified.
What of the post mortems themselves? The use of less-invasive post-mortem techniques such as CT scanning has more than doubled over the past year (from 764 cases in 2016 to 1671 in 2017). Two thirds of Coroner Areas now report having ordered at least one less-invasive post-mortem and this is a trend that is likely to continue.
One of the main catalysts behind the 120% increase in the use non-invasive PM techniques is the recent advance in the diagnostic accuracy of post-mortem imaging. Until recently non-invasive PM examinations by CT scanning (PMCT) alone were considered insufficiently reliable to permit them routinely to replace the traditional invasive autopsy. That changed with the advent of the adjunct technique of targeted coronary angiography. An injection of dye into the blood vessels supplying the heart is used to enhance post-mortem CT scanning and it means a cause of death can be provided in over 90% of cases by using this minimally-invasive PMCT imaging technique alone.
The University of Leicester team led by Professors Rutty and Morgan published their impressive research findings in The Lancet last year[1]. Their prospective controlled study showed how there was a 92% concordance between the cause of death identified with enhanced PMCT when compared to that revealed by an invasive autopsy plus PMCT. And the frequency of errors between the two individual approaches was not significantly different. Indeed in 5% of cases, PMCT revealed a clinically significant finding that had not been detected at autopsy alone. The research team concluded that for most sudden natural adult deaths investigated by coroners PMCT was a safe and reliable substitute for invasive autopsy.
At the beginning of May 2018 a much larger international multi-centre research study was published that has replicated the Leicester findings[2]. Analysis of combined results from 500 human bodies studied at nine centres throughout in Europe demonstrated that PMCT performs surprisingly well compared to conventional autopsy – it identifies 90% of forensically relevant findings compared with 61% for autopsies.
After the death of a loved one it can be extremely distressing to families to be told that a post-mortem is necessary. A post-mortem takes place behind closed doors for good reasons. The standard evisceration requires the chest and abdomen to be opened through a Y shaped incision, the rib cage broken open, the main organs removed weighed and examined, and the vault of the skull removed so the brain can be examined. Organs are replaced in the abdominal cavity, in a plastic bag, before the body of the deceased person is reconstructed.
The invasive autopsy is an important tool in modern death investigation, but it is right that we look critically at whether it should be the mode of investigation of choice. England and Wales have one of the highest invasive post-mortem rates in Europe[3] despite a nationwide shortage of pathologists and histopathologists to conduct traditional coronial invasive PMEs. Yet the research evidence now strongly suggests that, but for economic considerations, the first-line investigation for post-mortem examination in many cases ought to be PMCT, to be followed by an invasive autopsy only where required.
The amelioration of distress to the bereaved, the ability to meet the religious and socio-cultural values of a number of faith communities, the reduction of delay in the PM process and the freeing up of histopathologists to spend more of their time on the living (meeting two week cancer diagnosis targets for example) are just some of the reasons why moving towards more frequent use of non-invasive autopsy by PMCT should now be an imperative.
Footnotes
[1] Diagnostic accuracy of post-mortem CT with targeted coronary angiography versus autopsy for coroner-requested post-mortem investigations: a prospective, masked, comparison study. Rutty et al, The Lancet 2017; 390: 145–54.
[2] Postmortem CT Angiography Compared with Autopsy: A Forensic Multicenter Study. Grabherr et al., Radiology, May 2018
[3] England and Wales carry out more autopsies in proportion to the total annual deaths by a margin of approximately 40% when compared to other jurisdictions. Other parts of the UK, (Northern Ireland and Scotland), are much more similar to other parts of the world. There is no evidence from other jurisdictions that the lower number of referred deaths and autopsy rates reduces the ability to meet the needs of justice or death certification. See Hutton Review 2015 page 73.