The FRCPath Part 1 Course Dr Rachel Carey Autopsy
Aims • Highlight areas of study required for the FRCPath Part 1 exam • Learn about medico-legal aspects of autopsy practice • Cover some important autopsy scenarios and special tests • Do some exam-style MCQ questions
2021 (new) Syllabus 1. Knowledge – Tested in Part 1 Exam and CHAT 2. Skills – Tested in CHAT
Autopsy Syllabus (knowledge •
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General • • Understanding of methods of identification • Understands pathologic basis of disease and macroscopic and microscopic pathology of various types of death • Describes the common tissue dissection processes relevant • to autopsy practice • Recognises the role played by APTs • Recognises the utility of clinical information in the autopsy • practice • Demonstrates knowledge of the main side effects of treatments and the complications of surgical procedures Autopsy technique • Demonstrates knowledge of, and ability to perform autopsies in various scenarios • • Cardiac disease of uncertain cause • Endocrine/metabolic death • Hepatic disease • Intra-abdominal disease • Neurological disease • • Renal disease • Respiratory disease Deaths in the Community • Understands the aim of the autopsy when deaths occur in the community and there are no suspicious circumstances. Microbiology • • Identifies the microbiological processes that are relevant to autopsies – eg meningitis, sepsis, pneumonia, endocarditis, TB, viral hepatitis
Other investigations • Describes those areas of haematology, biochemistry, medical genetics and other investigative modalities that are relevant • How to take appropriate samples Histology • Describe the histological appearances of various common fatal conditions Consent • Is aware of current policy in relation to consent for autopsies and for tissue/organ retention • Is aware of current policy in relation to tissue/organ donation • Identifies the legal basis of consent to autopsy examination and circumstances for which consent is not required Health and Safety • Describes relevant protocols and documentation of working practices and practicalities of mortuary practices • Describes and explains regulatory aspects of health and safety issues Coroner/Procurator fiscal service regulations • Demonstrates familiarity with the need to report deaths to the appropriate legal authority in the four countries of the UK • Understands the preliminary enquiries that may take place via the coroner/procurator fiscal Demonstration of autopsy findings • Demonstrates awareness of communicating relevant autopsy findings to clinicians
In this 1. Death Certification presentation… 2. 3. 4. 5. 6. 7.
Medical Examiner System The Coroner The Human Tissue Act and Consent Special Tests at autopsy Important autopsy scenarios Virtual Autopsy
1. Death Certification
Death Certification • Why certify a death?
• Allows family to register death, arrange disposal of body and settle their estate • Helps family understand death • May help inform family about risk factors relevant to their own health • Monitoring of population health • Prioritise medical research/health services • Identify risk factors that may contribute to death
• Who can certify a death?
• A doctor who… • attended the deceased in their last illness (GP, hospital team) • Should have seen the deceased within the last 28 days (if not, discuss with coroner) • Must be confident of the cause of death “to the best of your knowledge and belief” • The coroner (after inquest, PM or both)
Updates to Death Certification Process • There is now a statutory duty to report deaths to coroner if required • Medical Examiner system • No separate cremation forms – now part of the unified certification process via the ME
New format for death certification Death No
Yes
occurs Is the death
reportable? Attending doctor prepares provisional MCCD and external examination
Report to Coroner
Death reported to Coroner Investigati on required?
Investigatio Investigations n not carried out - PM, required Inquest
MEDICAL EXAMINER: Scrutiny of medical info, talk to relatives and clinicans
MCCD issued Registrar: registers death, issues crem/burial cert. Cremation or
2. The Medical Examiner
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Medical Examiner Role New role now being introduced – to try to
increase scrutiny in to non-coronial deaths • Starting in acute trusts, but now being rolled our to examine all non-coronial deaths • Functions of The Medical Examiner: • to ensure that cases which should be reported to the Coroner are in fact reported • to ensure that medical certificates of the cause of death are as accurate as possible. • to provide opportunities for the bereaved to raise concerns • to provide advice to the Coroner and doctors
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Medical Examiner Role Medical Examiners
• Senior doctors contracted for a number of sessions per week alongside their other work • Oversee ME process • Medical Examiner Officers • Staff the medical examiner office full time • Come from a variety of backgrounds • Provide continuity to the service • Can perform roles such as scrutinise notes, discuss with clinicians and relatives etc
A.
Who is going to fund Medical Home OfficeExaminers?
B. NHS England C. Primary care trusts D. Charitable groups E. Local Authorities
3. The Coroner
The Coroner’s rules relevant to the PM (in the Coroner’s and Justice – WHEN –Act) rule 5: “as soon after the death of
the deceased as is reasonably practicable” – WHO – rule 6: “fully registered medical practitioner” whenever practicable, by a pathologist with suitable qualifications and experience – WHO ELSE – rule 7: “Coroner to notify persons of post-mortem to be made” - a list of properly interested persons to be informed of the PM and who may be present, or represented, at the PM – WHERE - rule 11: “(1) No post-mortem examination shall be made in a dwelling house or in licensed premises. (2) Every post-mortem examination shall be made in premises which are adequately equipped
Deaths reportable to the Coroner/PF: • Need to establish cause of death • Unknown cause of death • Sudden unexpected death (SIDS, SADS, SUDEP) • Deceased was not seen by the doctor within the 28 days before death • Death may be unnatural • Violent or suspicious • Possible manslaughter/murder • Due to an accident • May be due to self-neglect or neglect by others • Possible suicide • Death may be related to poisoning/drugs/acute alcohol poisoning (though not other forms of alcohol-related death) • Death may be a result of medical treatment • Death occurred during an operation or before recovery from the effects of an anaesthetic • Deaths secondary to medical treatment • Deaths where the conduct of a member of staff is questioned • May be due to abortion • Other • Deaths during or shortly after detention in police or prison custody • Industrial disease or related to employment
The Independent judicial officer Coroner Must be legally qualified for 5 years
• • • Role of the coroner… • Identify the deceased • Determine how, when and where they came about their death • Issue death certificate • Maintain records • Can order a post-mortem examination of the body, if needed to determine the cause of death. • Each Coroner has a defined area of jurisdiction (and responsible for all bodies lying within their jurisdiction) • A body can only be moved from one jurisdiction to a neighbouring one, by formal arrangement
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Coroners Public legalInquests inquiry held by the Coroner if: – Death is violent or unnatural – Death took place in prison or police custody – Cause is still uncertain after a postmortem
• Held in a court and may have a jury • Consists of coroner and next of kin (as a minimum) • May also have witnesses, GP, pathologist, hospital doctors, police etc
Coroners Inquests • The Coroner reaches a conclusion (verdict), which can be one of….. o o o o o o o o o o
Death by natural causes Death by misadventure Accidental death Unlawful killing Suicide Occupational disease Drug abuse Self-neglect An open verdict A narrative verdict
Fatal Accident Inquiry (Scotland) • Equivalent of an inquest • FAI held by the Procurator Fiscal (Scotland) if: – Death is caused by employment – Death took place in legal custody – Issue of public safety or general public concern • Held much less often than Coroners inquests • Held in private usually
A.
Which of the following IS correct? Any qualified doctor may issue a death certificate so long as they see the deceased after death.
B.
The consultant may request a hospital post mortem before issuing a certificate of cause of death.
C.
The Registrar may report deaths to the Coroner if the certified cause of death appears incorrect.
D. The Coroner must order a post-mortem examination on any death due to accident.
Which one of these deaths would NOT need to be reported to a Manchester area Coroner? A. Woman from Scotland who dies in a motor vehicle collision in Manchester B. Manchester resident who dies in a climbing accident on holiday in Wales C. Man from Liverpool who dies from drowning in France and body is returned via Manchester airport D. Child from Leeds who dies suddenly whilst staying with relatives in Manchester. E. Chinese visitor who unexpectedly collapses and dies on arrival in Manchester airport.
Which of these deaths would NOT need to be reported to the Coroner? A.
An ex-dockyard worker who dies due to known fibrotic interstitial lung disease. B. Woman dies due to metastatic breast cancer. Seen regularly by her GP until last week but GP now away on holiday for 2 weeks. C. A 45 year old who is taken to hospital after binge drinking, dying shortly after admission with a very high blood ethanol level. D. A 45 year old with hepatic cirrhosis due to excessive alcohol use who dies of liver failure in hospital. E.Young woman who has taken 30g of
Which of these deaths would NOT need to be reported to the Coroner? A.
An ex-dockyard worker who dies due to known fibrotic interstitial lung disease. B. Woman dies due to metastatic breast cancer. Seen regularly by her GP until last week but GP now away on holiday for 2 weeks. C. A 45 year old who is taken to hospital after binge drinking, dying shortly after admission with a very high blood ethanol level. D. A 45 year old with hepatic cirrhosis due to excessive alcohol use who dies of liver failure in hospital.
You have performed a Coroner’s autopsy on a case of death due to an industrial injury. To which ONE of the following legitimately interested parties must you give a copy of your PM report at their request? A. The next of kin of the deceased B. The Solicitor of the next of kin of deceased C. Health & Safety Executive officers investigating the case D. The senior police officer investigating the case E. The Coroner responsible for the case
4. The Human Tissue Act
The Human Tissue Act • •
Set up in 2005 after a culture of retaining tissue and organs without consent was revealed Regulates “relevant material” for the following reasons: • Autopsy • Anatomical examination • Public display of tissue • Tissue used in education and research
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It covers England, Wales & N.Ireland; Scotland has a separate law HT (Scotland) Act 2006.
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The Human Tissue Authority implements the Act
The Human Tissue Act • Exceptions: • Does not apply to tissue removed before September 2006 • Does not apply to tissue removed from the living for diagnosis or treatment • Does not apply to images - GMC standards for this • Does not apply to Coronial or Home Office PMs (but does apply to the material once the coroner’s/home office purposes are
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“Relevant Material”
Any material which consists of or includes human cells Therefore includes…. • Human bodies, organs, tissues, skin, bone, body fluids (bile, breast milk) • processed tissues that contain cells, • cell deposits or tissue sections on microscope slides • aspirated serous fluids and cyst fluids • pus, sputum, urine, stomach contents and bodily waste • umbilical cord stem cells • It does include hair and nails from the deceased Does not include…. • • • • •
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Gametes and embryos created outside the body (regulated separately by human fertilization and embryology act) Hair and nails from a living person (but does cover hair and nails from deceased person!) Any tissue collected from a living person for diagnosis or treatment Tissue collected before 2006 Serum and sweat are thought to be acellular
NB fetal tissue <24 weeks is counted as tissue belonging to the mother
“Scheduled Purposes”
ie Activities for which consent and licensing are required: •Anatomical examination
•Determining cause of death •Establishing effectiveness of treatment •Public display •Research •Transplantation •Audit, Teaching, QC, Public health monitoring
The HT Authority
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Established 2005, to implement the HT Act
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Provides advice and guidance about: the Human Tissue Act (2004) and the Quality and Safety Regulations (2007).
The Human Tissue Authority is an independent watchdog that protects public confidence by licensing and inspecting organisations that store and use tissue (for scheduled purposes under the Act)
The HT Authority
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Codes of Practice – covering postmortem practice, consent for use of human tissue, and disposal of human tissue.
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Regulation of people, premises and practices involved in post-mortems. Assessed by site inspections and audits.
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Sets rigorous standards for taking consent
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Disposal options must be offered to relatives for any tissue retained from PM
Consent under the • HTA Consent required for all scheduled
purposes involving any relevant material
• Except for Coroners’ or Home office PMs or samples retained for their investigations • After the Coroner’s function has ceased, then consent is required for further use or storage of material under the HTA rules.
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Consen tby the Deceased, or their Can be given Nominated Representative, otherwise:
• The Hierarchy of Qualifying Relationships is: • Spouse / civil partner, • child/parent, • full sibling (if >1, they must all agree), • grandchild/grandparent, niece/nephew, stepparent, half-sibling….. Lastly, long-standing friend.
The Process • PM carried out and tissue retained under the coroner’s act to establish cause of death • Must give details to coroner of all tissue retained • After cause of death is established, HTA takes over • Coroner gains consent for what happens to tissue afterwards. Options are: o Return - Return of the material to the family o Retention - Allow retention for research/other purposes o Disposal - Lawful and appropriate disposal by the pathologist
You wish to use mesothelioma samples taken from Coronial PMs in your hospital since 2010, for an approved cancer research project. Whose consent is required for use of each tissue sample? A. The HTA designated individual for the Trust B. The pathologist who reported the case C. H M Coroner D. No consent required E.The nominated representative or highest ranked relative of the deceased person
Which ONE of the following is NOT potentially a criminal offence under the HT Act 2004? A. Performing DNA analysis on a hospital post- mortem sample without specific consent. B. Using photographs from a postmortem for a teaching course, without consent. C. Using a retained heart for research following Coroners PM, without relatives’ consent. D. Retaining only a sample of hair
5. Special Tests at Autopsy
Special Histology - 20- 30% •Investigations cases
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Toxicology - 10% cases
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Biochemistry
Microbiology - 0- 5% cases Mineral fibre analysis Genetic studies
Toxicolo gy
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Drugs can be quantified in : blood, urine,
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Pitfalls:
Drugs can also be detected in: muscle, hair, liver, gastric contents, vitreous
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Redistribution after death
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Drugs can be released from tissues back in to blood
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Why peripheral sites are best
Microbial fermentation
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Particularly affects alcohol Can use it up or produce it
Toxicolo Relationship of toxicology findings to gy death:
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Direct toxicity as COD, eg illicit drug use
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Toxicity contributing to death eg opiates and respiratory disease
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Intoxication leading to traumatic death, eg alcohol and RTCs
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Intoxication affecting mental state in suicide
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Lack of compliance with
Microbiolo gy
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Most bacteriology not useful due to redistribution and colonisation after death, contamination and prolonged post-mortem intervals
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Blood cultures must be taken within 15h, sterile method prior to opening body
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CSF culture possible PCR for non-commensal organisms is effective eg: PCR for meningococcus (CSF), legionella (urine), H1N1 (throat swab)
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TB culture on tissue from caseating lesions
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Clostridium difficile toxin in stools
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Biochemist ry
Vitreous
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glucose, lactate, ketones, sodium, urea
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Uses: alcoholic or diabetic KA, dehydration
Blood
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Ketones (beta-hydroxybutyrate) Carboxyhaemaglobin for CO Mast cell tryptase – anaphylaxis Cholesterol level
Urine
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Dipstick for glucose, ketones
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Other Investigations Mineral fibre analysis for asbestos: • varies with region and lab method, correlate result with local lab ranges
• > 100,000 fibres/g dried lung for asbestosis • Sample destroyed in processing
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Genetic studies - only with specific permission
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use fresh or paraffin embedded spleen Eg for inherited cardiomyopathy
Which of the following tests is most likely to be useful in investigating the death of a poorly- controlled insulindependant diabetic man who was discovered dead at home, with no cause found grossly at autopsy? A. Blood for glucose level B. Blood for insulin level C. Vitreous for ketones and glucose level D. Blood cultures E. Vitreous for insulin levels
A 22 year old female student collapses outside a bar late at night and cannot be resuscitated. Which ONE of the following PM toxicology results most likely indicates her cause of death? A.Blood ethanol level 450 mg/dL (NB legal limit for driving is 80 mg/dL) B.Cannabinoids present at high levels in blood and urine C.Hair samples show chronic use of ecstasy, amphetamines, cannabis and sertraline D.Codeine, morphine and morphine metabolites all present (at low levels) in blood and urine E.Lack of anti-convulsant medication in blood or urine.
6. Important Autopsy Scenarios
RCPath Autopsy Best Practice Scenarios
1. Sudden death with likely cardiac pathology 2. Epilepsy 3. Occupational lung disease 4. Anaphylaxis 5. Illicit drugs 6. Sickle cell 7. Maternal
8. Neuropathology and brain trauma 9. SUDI/stillborn/neonatal death
Sudden Cardiac Death
These are likely to be one of the following, depending on age and circumstances of death: • Ischaemic heart disease • ?Familial hypercholesterolaemia if young age • Hypertensive heart disease – dilated and hypertrophied • Valvular heart disease – Ao stenosis, endocarditis • Cardiomyopathy • Inherited – HCM, DCM, ARVC • Alcoholic – dilated • Rare others – sarcoid, amyloid, infections, tumours, coronary anomalies • SADS • Channelopathies
SAD = Sudden Arrhythmic S Death Syndrome
•No cause of death found grossly, histologically or on toxicology
• Diagnosis of exclusion •Heart should be examined by specialist histology of conducting systems etc
% due to non-structural channelopathies causing fatal arrhythmia, often genetic e.g Brugada syndrome, long QT, short QT, -> Counselling and investigation of relatives
Cardiomyopathy HCM • Hypertrophic cardiomyopathy •Autosomal dominant, sarcomere gene mutations • Macro: LVH, asymmetric septal hypertrophy, heart weight increased • Micro – myocyte disarray
Cardiomyopathy DCM
• Dilated cardiomyopathy
• Usually acquired – alcohol, pregnancy, chemotherapy etc alcoholism, viral myocarditis • or can be Familial (30%) – usually mutations in mitochondrial or cytoskeletal genes • Causes congestive heart failure
Cardiomyopathy ARVC
Arrhythmogenic right ventricular cardiomyopathy • Autosomal dominant inheritance • Gross: Right ventricular thinning +/- fatty infiltration •Micro: fibro-fatty replacement of myocytes, +/- inflammation
Which of the following features is NOT associated with sudden arrhythmogenic death syndrome (SADS)? A.Young age and previously fit and
well B.Heart appears structurally
normal at autopsy C. Death occuring during physical
exertion D.Inherited genetic mutation found on
family screening
Deaths Associated with Epilepsy Types of epilepsy deaths:
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status epilepticus
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accident due to seizure - trauma or drowning
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aspiration or asphyxia due to seizure
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complication of treatment
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SUDEP
Epilepsy Deaths Sampling
Ideally specialist referral and whole brain fixation for 2-3 weeks before sampling 2 coronal slices of brain 1.5cm thick (pre and post midbrain): photograph and sample specific areas (x8, bilaterally) Myocardium, Lung, other organs Blood and Urine for drugs, alcohol and
SUDEP
must have ante-mortem epilepsy diagnosis or strong history of seizures no other cause of death found mechanism of death not known - thought to be neurogenic cardiac arrhythmia or respiratory
A 18 year old man with a past history of epilepsy is found dead at home with evidence of urinary incontinence. No macroscopic abnormalities are seen at PM examination. You retain the brain. What are the most likely histological findings? A. Amyloid plaques B. Intranuclear inclusions within neurons C. A histologically normal brain D. Patchy demyelination E. Diffuse spongiosis of the grey and white matter
Anaphylax is anaphylaxis: Modes of death from • Airway: Asphyxia due to Laryngeal oedema - eg insect sting, food • Lungs: Asthmatic attack - eg aspirin and food allergies • Circulation: Shock - eg drug allergy Misdiagnosed commonly as an MI or Asthma attack • NB myocardial ischaemia inevitable in shock • pulmonary oedema may be due to epinephrine use • can differentiate acute from chronic asthma
Anaphylax is evidence of allergen: Look for serological •
serum drug levels •specific IgE levels for foods, beesting,
drugs Look for biochemical evidence of anaphylaxis • Mast cell tryptase - samples useful up to 3 days post death • Total IgE levels - stable at room temperature for 11
A 14 year old girl collapses and dies at a party after eating birthday cake. At postmortem there is laryngeal oedema. What is the most useful sample to retain to confirm the cause of death? A. Peripheral blood for mast cell tryptase B. Histology of the larynx C. Urine for drug screen D. Peripheral blood for ketones E. Stool sample for culture
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Maternal Deaths International definition: death during pregnancy or within 6 weeks of delivery/miscarriage.
• UK definition includes deaths up to 12 months – ‘early’ (<6 weeks/ 42 days) – ‘late’ (>6 weeks)
• NB: all maternal deaths are scrutinised for the UK Confidential Enquiry into Maternal Death.
• Autopsy by a specialist pathologist recommended
Maternal Death • Direct: can only occur in pregnancy • eg eclampsia, uterine rupture, PPH, molar pregnancy, peurperal sepsis, ectopic pregnancy, amniotic fluid embolism
• Indirect: exacerbated by pregnancy • eg Congenital heart defects, breast cancer, epilepsy- SUDEP, diabetes, H1N1 flu, sickle cell disease
• Coincidental: • eg road accident, illicit drug overdose, unrelated malignancy.
A 40 year old woman develops shortness of breath, collapses and dies following a complicated full-term delivery. Histology of the pulmonary vessels demonstrates intravascular squames and mucin. What is the most likely cause of death?
A. Pulmonary thromboembolism B. Squamous cell carcinoma C. Amniotic fluid embolism D. Eclampsia E. DIC
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Occupational Lung Disease Dept for Work & Pensions classifies prescribed Occupational Diseases on advice of Industrial Injuries Advisory Council
• Once diagnosed, can apply for government compensation • Deaths reportable to Coroner
Occupational lung disease • Role of the autopsy? • confirm lung disease • evidence of occupational exposure • relevance to cause of death Commonest cases now are asbestosrelated (coal, cotton, silica etc very rare)
• pleural
plaques •mesotheliom a
Asbesto s
Asbestos-related deaths include any direct or indirect death resulting from:
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asbestosis (fibrosis)
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mesothelioma
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carcinoma of lung – any type
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diffuse pleural thickening or benign pleural effusions
Must demonstrate adequate asbestos exposure...
Asbesto s
A 68 yr non-smoking dock worker dies following 6/12 history of increasing SOB and chest pain. PM examination finds an extensive tumour encasing the right lung. What is the most likely cause of death? A. Squamous cell carcinoma of the lung B. Metastatic colorectal carcinoma C. Mesothelioma D. Pulmonary fibrosis E. Small cell lung carcinoma
7. Virtual Autopsies
Virtual Autopsies MR scan • Non Invasive technique
• Used for religious /cultural reasons, forensics or mass disasters • Can yield high quality, 3D, high res images • Disadvantages: – Cannot sample body for microorganisms or toxins – Cannot type tumours etc – Limited availability and expense, of scanners and radiologists
Suggested Reading • Robbins Pathologic Basis of Disease • Knight’s Forensic Pathology • Simpson’s Forensic Pathology • The Hospital Autopsy – GN Rutty, J Burton • Gross pathology atlases
Resources on College Website • Guidelines on Autopsy Practice (RCPath, 2002) • RCPath Best Practice Scenarios, 2005 • Autopsy and Audit • Code of Practice and Performance Standards for Forensic Pathologists • A Brief Guide on Consent for
For Further information…
• www.e-lfh.org.uk/projects/medical-examiner : about medical examiner role and online training • https://www.gov.uk/government/publications/ guidance-notes-for-completing-a-medicalcertificate-of-cause-of-death • http://www.ons.gov.uk/ons- look up “Death certification reform - A case study on the potential impact on mortality statistics” • http://www.doctors.net.uk/education : module on “Post- mortems and Death Certification” (current system) • www.mps.org.uk – factsheets on death certification, Coroners inquests and procurator
THANKS FOR LISTENING ANY QUESTIONS…?