Abstract and Introduction
Abstract
The decline of the hospital autopsy is a well-known phenomenon that shows no sign of ending. Debate continues for the reasons behind this, but inadequate consent practices are thought to play a role. The furore resulting from organ retention scandals at Bristol Royal Infirmary and The Royal Liverpool Children's Hospital led to widespread soul searching in the medical profession, and a fundamental change in how we treat the dead body. In response, the 2004 Human Tissue Act was created, and consent is now centrally placed to permit all activities dealing with the cadaver, including autopsy. This article reflects on consent practices for hospital autopsy in England and Wales. Relevant policies from 26 National Health Service trusts were examined against the recommended standards set by the Human Tissue Authority. We found numerous failures of multiple trusts to follow these standards. Several trust policies failed to outline basic information to guide staff in conducting the consent process, such as the training requirements of the consent taker, and the desired approach to take consent. Many trusts failed to outline vital recommendations of the Human tissue Authority, such as the requirement of the consent taker to be experienced, trained in dealing with the bereaved and well informed on autopsy practice, as well as the requirement to have witnessed an autopsy. We recommend trusts reassess their practices in order meet the established standards with an emphasis on educating staff and developing a team-based approach to consent taking.
Introduction
The autopsy (meaning 'to see for oneself') has played an integral role in the understanding and discovery of disease for most of the 20th century, and continues to have an important role in modern medicine.
It is well documented that the autopsy has been in decline for decades. Falling hospital autopsy rates have been attributable to the majority of this change, whereas coroner's autopsy rates have remained relatively constant over this period. The reasons for this decline are complex, but past organ retention scandals, such as those stemming from the public inquiries of Bristol Royal Infirmary and The Royal Liverpool Children's Hospital, have played a part. These inquiries into child autopsy practice and organ retention led to a change in the legislation; under the Human Tissue Act 1961 it was only necessary to demonstrate a 'lack of objection' for postmortem (PM) examination and organ retention to take place. The creation of the 2004 Human Tissue Act (HT Act) ensued, which placed consent centrally for all PM procedures permitted under the act, including autopsy. A hierarchy of consent for autopsy was established:
Consent from the deceased in life
Consent from a nominated representative
Consent from a person on the highest ranking qualifying relationship
Ranked from spouse/partner (top) to friend of long standing (bottom).
Altered public and professional views towards autopsy in the aftermath of the two inquiries are thought to have led to inadequate consent practice, further fuelling the declining autopsy rates. It has been shown repeatedly that increasing the number of requests to families can significantly improve autopsy rates, suggesting that currently there is a failure to realise the potential for higher hospital autopsy rates. Moreover, it has been shown that some National Health Service (NHS) trusts have been failing to comply with their statutory duties with respect to this issue.
This article reflects on some of the methods for PM consent employed by trusts in England and Wales. We aim to identify potential areas of improvement and seek to answer these important questions: Are the consent processes employed by NHS trusts meeting the recommended standards? Are they suitable for purpose?