Summary
The Coroner
5. Organs and tissue were removed
and retained at post mortem examination. The provisions of Section
1 (2) and 1 (3) of the HTA apply to retention following hospital
post mortem examination. The Coroner has no power to authorise retention
of organs for the purposes of medical education and research upon
conclusion of a Coroner's post mortem.
6. A clouded view of what the
Coroner's jurisdiction requires of clinicians has emerged generally
in the course of our Inquiry. There was a lack of precision in the
minds of clinicians as to when a death is strictly reportable to
the Coroner. Failure to carry out a Coroner's post mortem examination
(CPM) in cases where such examination should be performed results
in a lack of proper scrutiny of medical practice and the benefits
of openness and transparency are lost.
7. The difficulties were compounded
in Liverpool because HM Coroner, Mr Roy Barter, considered the decision
whether to carry out a CPM as a simple administrative decision
which he wrongly delegated to the Coroner's Officer. The decision
is one to be taken personally by the Coroner. If there is an intention
to retain organs for medical education and research upon conclusion
of the Coroner's jurisdiction, the clinician should obtain consent
from the Coroner and the parents at the outset, otherwise retention
following completion of a Coroner's post mortem examination is illegal.
8. Mr Barter had no proper system
for specifying the cases in which histology was required or identifying
the organs or tissue to be preserved for histological examination
by the pathologists. On several occasions, Sudden Infant Death Syndrome
(SIDS) was accepted by him as the proper cause of death without
histological examination being carried out, when he knew or should
have known that SIDS was a diagnosis of exclusion. In failing to
insist upon histology, he must have recorded an inaccurate cause
of death in a number of cases.
9. He should have known that
the reports he received from Professor van Velzen were preliminary
reports without histology, particularly in SIDS cases. His systems
were
inadequate and there was no system for chasing up histology or final
reports.
10. Clinicians were uncertain
as to which deaths should be reported to the Coroner. Some clinicians
applied the threat of a Coroner's post mortem examination to obtain
consent to a hospital post mortem examination. The Liverpool Coroner's
Officer in determining whether there should be a Coroner's post
mortem examination was satisfied as to the cause of death identified
by the clinician in circumstances where the Coroner might well not
have been satisfied.
11. Slackness in Mr Barter's
procedures undoubtedly contributed to the delay in identifying Professor
van Velzen's abuse of post mortem procedures.
