Preventable deaths will increase as post-mortem exams die, say doctors

On one score Professor Gunther von Hagens is to be congratulated. The self-promoting showman responsible for the Body Worlds show of preserved corpses has brought post-mortem tests and their role in medical science to public consciousness in a way that earnest entreaties from royal colleges have failed to do.

The maverick German doctor declared yesterday that doing a public autopsy was important for "educating people about their bodies and about death". While his motives may be questioned for playing to the public's fascination with death, there can be no doubting that education is exactly what the public, and the medical profession, need.

For the post-mortem examination is in a critical state. It is going out of fashion and doctors fear that the decline has reached the point where their rarity now threatens the living. The hour spent by the pathologist with the corpse on the slab in the mortuary can disclose details about the death that could prevent future ones.

The Royal College of Pathologists warned after the Alder Hey organ retention scandal last year that the number of post-mortem tests had fallen to "dangerously low levels". Yet in 15 per cent of cases the examination shows that the diagnosis was wrong to the extent that different treatment should have been given. That suggests that, in one in six cases, patients who had been given a different drug or a different operation might have survived longer. But without such work the secret of their undisclosed illness dies with them.

Thirty years ago, most people who died in hospital had a post-mortem test. Today only a tiny fraction do. Of 556,000 deaths reported in England and Wales in 1999, just 3,330 (0.6 per cent) were followed by a post-mortem examination instigated by a doctor.

Professor Sir John Lilleyman, president of the Royal College of Pathologists, said yesterday: "We are not doing enough hospital post-mortems and that will eventually impact on patient care. The problem is that post-mortems don't help meet government targets and no one wants to pay for them. There are no post-mortems in the private sector and the NHS does not give them high priority."

The decline has been driven in part by growing public distaste. Although there is a public appetite for grisly displays of body parts in horror movies and medieval torture museums, permitting the dissection of a relative or friend, even for the benefit of medical science, is an idea that offends many.

Professor Lilleyman said: "People don't like the idea of being messed about. A common response to the request for a post-mortem is, 'He or she has suffered enough'." Improved methods of diagnosis using hi-tech imaging equipment, such as MRI scans, and growing confidence among doctors that they know the cause of death have also fuelled the decline. "Most people dying in hospital have a diagnosis and maybe clinicians feel they don't need to go through the autopsy. On the other hand, research shows 10 to 15 per cent of post- mortems reveal the diagnosis was wrong," the professor said.

Most examinations are ordered by coroners. In 1999 there were 100,000 coroners' tests in England and Wales, representing 18 per cent of the total number of deaths.

A coroner's post-mortem examination has a different aim from a hospital's – to discover where and how the person died, but not why. The task of the pathologist appointed by the coroner is to ensure that the death was natural and explicable and not due to neglect or malicious intent.

Coroners' post-mortem examinations are due for a shake-up under a review being run by the Home Office. More are done in Britain than in other countries and some of the rules are archaic, such as that a post-mortem examination must be ordered if a patient has not seen his or her GP in the three weeks before death. However, there are also concerns that the system failed to uncover the activities of Harold Shipman, the serial killer GP.

The need for reform is urgent. The annual study of deaths following surgery in hospital, the National Confidential Enquiry into Perioperative Deaths, warned earlier this month that the post- mortem examination was "pivotal" to revealing "errors in decision making, team working, diagnosis and technical performance" and the imbalance between coroners and hospital examinations was endangering patients.

The report said: "The result is that the autopsy has become a process that has lost its link with clinical medicine. The coronial system, unlike hospital autopsies, was not set up to help clinicians [and] is failing to provide the lessons we need to learn in order to understand a patient's death"

Efforts to revive support for post-mortem tests suffered a grievous setback in the late 1990s with the disclosure that a pathologist, Professor Dick van Velzen, at Alder Hey children's hospital in Liverpool, had used them as an opportunity systematically to strip the bodies of children. He had stockpiled 2,000 organs in a basement in the city taken from 850 children without the consent of relatives.

A government inquiry into the scandal, published in January last year, revealed almost 105,000 body parts were held in hospitals around the country, which had been removed without relatives' consent.

The inquiry demonstrated that the organ retention scandal extended far beyond Alder Hey to include every hospital where organs were stored following post-mortem examinations. The disclosure rocked public confidence and accelerated the decline in post-mortem tests. Public outrage and strict new guidelines on obtaining consent led to a further fall in the number. There were protests over the scale of the practice, with campaigners claiming more organs were taken than could ever have been used.

This was based on a misunderstanding. The collections of organs, including an estimated 11,000 children's hearts stored nationwide, were in effect huge data banks established with the prospect that they might reveal their secrets years, or decades, later.

As new hypotheses about the cause of disease were formulated, researchers would have a resource on which they could selectively test their theory. But this depended on keeping a large number of organs, not all of which would be used in the research.

The damage has, however, been done. The Alder Hey scandal further undermined trust in doctors and the medical process.

Relatives have become more resistant to giving consent for post mortems and doctors more reluctant to seek it. Our understanding of death is thus impaired. The result is that the deceased are left undisturbed but it is the living who are the losers.

Autopsy through the ages

The dissection of the human body in the service of medical science challenges an ancient taboo against desecration of the dead. The first recorded instance of medical dissection of human bodies was in the sixth century BC when the Greek philosopher Alcmaeon began his research. But many subsequent physicians were forced to work clandestinely.

Christian doctrine promises resurrection of the dead and many thought this impossible if the body was anatomised. In the 12th century the Church prohibited dissections in the hope of curtailing the practice of dismembering and boiling the bodies of Crusaders killed in battle before their shipment home.

Interest in anatomy was revived during the Renaissance, in part due to the work of artists such as Leonardo da Vinci, but the prohibition on dissection remained. Andreas Vesalius, one of the founders of modern anatomy, was sentenced to death by the Inquisition for the dissections that informed his masterpiece De corporis humani fabrica, published in 1543.

The right to conduct dissections was granted to the Royal College of Physicians in England in 1565, after the Reformation freed doctors in Protestant countries from the authority of the Catholic Church. They then faced the problem of obtaining cadavers for the purpose.

Condemned criminals provided the chief source and the threat of dissection served as an added deterrent to crime as many people regarded anatomisation as worse than hanging itself. But competition for bodies was so intense that many surgeons turned to grave robbing and hiring body snatchers such as Burke and Hare in Edinburgh.

In 1829, William Burke was hanged in Edinburgh for murdering victims by asphyxiation to supply the medical school trade. Three years later, in 1832, a law was passed making it possible for doctors to obtain cadavers without resorting to body snatching. That formed the basis of the 1984 Anatomy Act, which regulates the handling of bodies in medical schools today.

The Government is in the process of considering responses to the public consultation on a proposed new law governing the removal, storage and use of tissue, the disposal of organs and tissue and the import and export of body parts.