Calls for more post-mortems after natural deaths
With 30% of death certificates in the UK found to be inaccurate, there are calls for more consented post-mortem examinations to be carried out to check the cause of natural deaths.
It is 08:30 and the body of a woman in her 40s is lying on the mortuary table in St Thomas' Hospital, London.
Anatomical pathology technologist Ruby Stewart has removed the hospital shroud from the woman's body and, after identification is checked by the overseeing professor, Ruby makes her first cut.
"I'm just going through the layers slowly but surely until I reach the abdominal cavity," she explains.
This is a consented post-mortem examination. The case has been referred because although the patient had an underlying heart problem, she had been responding well to her treatment for pneumonia but had suddenly and rapidly deteriorated.
"I don't think we expected her to die the way she did," says Sebastian Lucas, professor of Pathology at St Thomas' hospital, who was in charge of the autopsy.
The majority of post-mortem examinations are requested by a coroner when an unnatural cause of death is suspected. In contrast, consented post-mortem examinations are performed when there is uncertainty about a natural death. They are requested by a doctor with permission from relatives.
Consented post-mortem examinations used to be the norm but last year, while there were 102,000 coroner-ordered autopsies, Professor Lucas estimates only 2,000 consented autopsies were carried out.
Professor Lucas remembers performing about a dozen post-mortem examinations a week to clarify why people died, teach medical staff and students, and improve clinical practice. But now he performs just one a week.
He believes this is a huge loss to medical science in terms of information and educational material.
"National statistics show that roughly 30% of death certificates are wrong - in a major or less than major way," he says.
"We are throwing away potentially valuable information by not doing more of the consented post-mortems," to find out what really caused their death.
He believes they would be a great source of information for cancer research and treatment in particular.
"About a quarter of people die of, or with, cancer in the UK. But cancer is hugely underrepresented in the mortuary room.
"When patients have been through the cancer treatment process... the cancer physicians generally contend that they died of advanced cancer.
"But actually they may well have died of infections. They might have died of complications of the therapy."
He says modern scans cannot answer all the questions after death as illustrated by the woman being investigated today. "She's had all the imaging in the world and we still don't know."
He believes there is a "reluctance to investigate deaths" by doctors as there is "an element of not being very interested, partly because someone has died and it may or may not be regarded as a failure, but they want to get on with the next case anyway."
Also, he says, pathologists have got used to not doing them and there is a change in how we treat death.
"If we wanted to advertise for lunchtime autopsy demonstrations for medical staff to attend, that would be unacceptable to the authorities. We don't advertise death, but we used to," he says.
The doctor who requested the autopsy on the woman paid a visit to the mortuary to find out what they had discovered.
"This is very useful because it's very rare that we see such pathology in front of our eyes," he says.
However it will be a few days before all the answers are given. Tissue samples need to be taken away and examined under a microscope.
Professor Lucas discovers that the woman had in her past been misdiagnosed with HOCM (Hypertrophic obstructive cardiomyopathy), a heart muscle disease that is potentially inheritable.
"This is very important we can now tell her children that there is no risk of them developing HOCM because their mother never had it," explains Professor Lucas.
He also discovers that the woman's heart valve had been damaged by an undiagnosed rheumatic fever. This is a disease associated with poverty in previous generations. "It is very surprising that she had it," he adds.
Professor Lucas concludes she died of heart and lung failure as a consequence of chronic rheumatic valve disease.
An autopsy costs the hospital £1,000 to carry out but Professor Lucas believes it is money well spent as it helps in "correcting areas where we have misapprehensions about why people are dying".
He adds: "If we don't do enough of these, we dumb ourselves down and I'm worried about the next generation of pathologists who won't have had the experience of looking at complicated cases, which require a lot of thought."
Post Mortem is on BBC Radio 4 on Wednesday, 14 December 21:00 GMT.