The Autopsy

The Autopsy FRCPath Part 1 Course

Dr Zuhair Alfadil

Aim • Highlight areas of study required for the FRCPath Part 1 • Learn about medico-legal aspects of autopsy practice • Cover some important autopsy scenarios and special tests • Do some exam-style MCQ questions

2010 curriculum Pathological basis of disease

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A wide knowledge of the pathological basis of disease and the macroscopic/microscopic pathology of various types of death

General

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Anatomy, macroscopic features of major diseases Common dissection techniques Understanding of the roles of APTs Autopsy technique Have knowledge of how to perform autopsies in a variety of situations

- See RCPath Best Practice autopsy scenarios

2010 curriculum Histopathology

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Knowledge of the autopsy histology appearances of common fatal conditions Ability to select appropriate tissue blocks

Toxicology and Other investigations

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Knowledge of relevant areas of toxicology, microbiology, biochemistry, medical genetics, etc How to take appropriate samples

2010 curriculum Consent

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Current policy in relation to consent for autopsies and for tissue /organ retention

Health and safety

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Knowledge of the regulatory aspects of health and safety issues

See: ‘Safe Working and Prevention of Infection in the Mortuary and Autopsy Suite’ (Health Services Advisory Commission)

Medico-legal issues •

Deaths reportable to the Coroner, Coroners rules

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knowledge of law relating to death certification, investigation and disposal of the dead

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(for those in Scotland - the Crown Prosecution and Procurator Fiscal Service)

In this presentation…

1.

2.

3.

4.

5.

6.

7.

Death Certification Recent reforms – 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 Who can certify a death?

• • •

A doctor who attended the deceased in their last illness* Must have seen the deceased within 2 weeks prior to death, or see them after death Must be confident of the cause of death “to the best of your knowledge and belief” *except Scotland

Current process of death certification Death occurs Is the death reportable?

Death reported to Coroner*

Attending doctor issues MCCD

Investigations carried out to satisfaction of coroner eg PM, Inquest duty to refer questionable cases

Cremation forms filled by 1st and 2nd doctor and medical referee

Cremation

Registrar receives MCCD, registers death, issues burial cert.

Burial

Current process of death certification No statutory duty for doctors to report a death to Coroner For cremations only, a 2nd and 3rd certificant are required - allowing some further scrutiny.

Around 45% of deaths end up referred to the Coroner of these, about 50% have a PM and 12% have an inquest

Changes to death certification All deaths not notified directly to Coroner will be scrutinised by an Independent Medical Examiner Doctors will have statutory duty to notify reportable deaths to coroner No separate crem forms - unified certification process via ME, fee charged for all death certifications

Estimated that only 35% of all deaths will be reported to Coroner

Changes to death certification Death occurs Is the death reportable?

Attending doctor prepares provisional MCCD and external examination

Death reported to Coroner Investigation required?

report to Coroner MEDICAL EXAMINER: Scrutiny of medical info, talk to relatives and clinicans

Investigations carried out - PM, Inquest

MCCD issued Registrar: registers death, issues crem/burial cert.

Cremation or Burial

Changes to death certification 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 advice to the Coroner and doctors to have a local overview of patterns in reported deaths

Who is going to fund Medical Examiners?

A. Home Office

B. NHS England C. Primary care trusts

D. Charitable groups E. Local Authorities

Which of the following IS correct?

A.

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.

E.

In UK, approximately 15% of deaths are reported to the Coroner.

The Coroner • Independent judicial officer

• Responsible for investigating certain categories of deaths, to establish the identity of the deceased, and how, when and where they came by their death.

• 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

• A body can only be moved from one jurisdiction to a neighbouring one, by formal arrangement between the Coroners.

• Procurator Fiscal has a similar role in Scotland

The Coroner’s rules (in the Coroner’s and Justice Act) – Who: Rule 6. “fully registered medical practitioner” whenever practicable, by a pathologist with suitable qualifications and experience

– 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 – When: “as soon after the death of the deceased as is reasonably practicable” – 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 for the purpose of the examination.”

– What: Rule 9. “A person making a post-mortem examination shall make provision, so far as possible, for the preservation of material which in his opinion bears upon the cause of death for such period as the coroner thinks fit” & “Schedule 2” - the format for the written report.

Deaths reportable to the Coroner/ PF: • Unknown cause of death • Deceased was not seen by the doctor within the 14 days before death • violent or unnatural or suspicious • due to an accident

• may be due to self-neglect or neglect by others • industrial disease or related to employment • may be due to abortion • Death occurred during an operation or before recovery from the effects of an anaesthetic • possible suicide • deaths during or shortly after detention in police or prison custody • Death may be related to poisoning

Coroners Inquests • Public legal 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 post-mortem • Held in a court and may have a jury

• Witnesses may be called to attend or produce statements • Inquisitorial not adversarial, must not assign blame

Coroners Inquests • The Coroner reaches a conclusion (verdict), or may produce a “narrative conclusion”.

• natural causes, • accident • misadventure, • industrial disease,

• suicide, • unlawful killing, • or ‘Open’

Fatal Accident Inquiry • 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

Coroners and Justice Act 2009 • All Coroners to be Legally qualified • Appointment of a Chief Coroner (a judge) and Medical Adviser to the Chief Coroner • National Medical Examiner & local Medical Examiners • Coronial authority for entry, search and seizure of evidence • Obligation for Coroners to inform persons / organisations of any actions required to prevent future deaths.

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 paracetamol & dies of liver failure in hospital.

The Human Tissue Act 2004 Replaces the Human Tissue Act 1961, the Anatomy Act 1984 and the Human Organ Transplants Act 1989.

It covers England, Wales & N.Ireland; Scotland has a separate law - HT (Scotland) Act 2006.

The Human Tissue Authority est 2005, implements the Act

The Human Tissue Act 2004 • Regulates removal, storage and use, of “relevant material” from the living or the dead • Authorises the use of human material for the “scheduled purposes” defined in the Act • Aims to restore public confidence after the ‘organ scandals’ (Bristol, Alder Hey)

The Human Tissue Act 2004 • 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

“Scheduled Purposes” ie Activities for which consent and licensing are required: •Anatomical examination •Determining cause of death •Establishing effectiveness of treatment

•Obtaining information that may be relevant to another •Public display

•Research •Transplantation •Audit, Teaching, QC, Public health monitoring

“Relevant Material” Any material (other than gametes) which consists of or includes human cells

It 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 (but not from living)

The HT Authority • •

•

Established 2005, to implement the HT Act

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) Provides advice and guidance about: the Human Tissue Act (2004) and the Quality and Safety Regulations (2007).

The HT Authority • • • •

Codes of Practice – covering post-mortem practice, consent for use of human tissue, and disposal of human tissue.

Regulation of people, premises and practices involved in post-mortems. Assessed by site inspections and audits.

Sets rigorous standards for taking consent Disposal options must be offered to relatives for any tissue retained from PM

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

Consent • In deceased, 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.

Consent • Can be given by the Deceased or their 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, step-parent, half-sibling….. Lastly, long-standing friend.

Which ONE of the following is NOT potentially a criminal offence under the HT Act 2004?

A. Performing DNA analysis on a hospital postmortem sample without specific consent.

B. Using photographs from a post-mortem 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 from the deceased, without consent.

E. Using stored PM histology slides for a demonstration to public at a hospital open day.

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

Special Investigations • • • • • •

Histology - 20- 30% cases Toxicology - 10% cases

Microbiology - 0- 5% cases Biochemistry

Mineral fibre analysis Genetic studies

Toxicology • • • •

Drugs can be quantified in : blood, urine, Drugs can also be detected in: muscle, hair, liver, gastric contents, vitreous

Understand drug redistribution, and breakdown of unstable compounds after death Effect of microbial fermentation on ethanol levels (up to 50 mg%)

Toxicology Relationship of toxicology findings to death:

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• •

Direct toxicity as COD, eg illicit drug use Toxicity contributing to death eg opiates and respiratory disease Intoxication leading to traumatic death, eg alcohol and RTCs

Intoxication affecting mental state in suicide Lack of compliance with medication eg epilepsy death.

Microbiology • •

• • • •

Most bacteriology not useful due to redistribution and colonisation after death, contamination and prolonged post-mortem intervals Blood cultures must be taken within 15h, sterile method prior to opening body CSF culture possible PCR for non-commensal organisms is effective eg: PCR for meningococcus (CSF), legionella (urine), H1N1 (throat swab) TB culture on tissue from caseating lesions Clostridium difficile toxin in stools

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Biochemistry Vitreous

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glucose, lactate, ketones, sodium, urea Uses: alcoholic or diabetic KA, dehydration

Blood

• • • •

Ketones (beta-hydroxybutyrate) Carboxyhaemaglobin for CO Mast cell tryptase – anaphylaxis Cholesterol level

Urine

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Dipstick for glucose, ketones porphyrins

Other Investigations •

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Mineral fibre analysis for asbestos:

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varies with region and lab method, correlate result with local lab ranges

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> 100,000 fibres/g dried lung for asbestosis Sample destroyed in processing

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 poorlycontrolled insulin-dependant 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% (NB legal limit for driving is 80 mg%) 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.

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 • SADS • Channelopathies

• Rare others – sarcoid, amyloid, infections, tumours, coronary anomalies

SADS = Sudden Arrhythmic Death Syndrome

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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 Primary cardiomyopathies – intrinsic disorders of cardiac muscle, inherited or acquired.

• Hypertrophic cardiomyopathy • Autosomal dominant, sarcomere gene mutations

• Gross: LVH, asymmetric septal hypertrophy, heart weight increased • Micro – myocyte disarray (>10%) • Association with athletes

Cardiomyopathy • Dilated cardiomyopathy

• Acquired eg secondary to pregnancy, drugs alcoholism, viral myocarditis • or Familial (30%) – various patterns of inheritance

• Causes congestive heart failure

Cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy • Autosomal dominant inheritance

• Associated with exercising - arrhythmias • 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 E.Histology of the myocardium shows myocyte disarray

2. Deaths Associated with Epilepsy What is the role of the autopsy?

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 anticonvulsants

Deaths in Epilepsy

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 arrest

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

Anaphylaxis Modes of death from anaphylaxis: • Asphyxia due to Laryngeal oedema - eg insect sting, food • Asthmatic attack - eg aspirin and food allergies • 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 histologically

Anaphylaxis Look for serological evidence of allergen: •

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 weeks Gastric contents ?

Mention the allergen on the death certificate where known.

A 14 year old girl collapses and dies at a party after eating birthday cake. At post-mortem 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

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)

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NB: all maternal deaths are scrutinised for the UK Confidential Enquiry into Maternal Death.

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Autopsy by a specialist pathologist recommended

Maternal Death •

Direct: can only occur in pregnancy

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Indirect: exacerbated by pregnancy

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eg eclampsia, uterine rupture, PPH, molar pregnancy, peurperal sepsis, ectopic pregnancy

eg Congenital heart defects, breast cancer, epilepsySUDEP, 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

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 asbestos-related (coal, cotton, silica etc very rare)

• pleural plaques •mesothelioma

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

Asbestos 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...

Asbestosis requires 2 ABs /1cm sq lung section, or suitable fibre burden Carcinoma requires background of asbestosis

Mesothelioma just requires history of exposure

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 – Not suitable for all cases

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 Pathologists • NCEPOD Coronial Autopsy Study

For Further information… www.e-lfh.org.uk/projects/medical-examiner : about medical examiner role and online training

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 “Postmortems and Death Certification” (current system) www.mps.org.uk – factsheets on death certification, Coroners inquests and procurator fiscal.

THANKS FOR LISTENING ANY QUESTIONS…?