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7 THE PATHOLOGIST'S AUTOPSY REPORT
7.1 Standard
The pathologist will:
a) produce a formal report that will record:
i) the relevant information the pathologist received in advance of the autopsy
ii) all investigations made either personally or by submission to a laboratory for report
iii) conclusions and an explanation for those conclusions. Where unusual features are found but are concluded not to be relevant, the pathologist must explain why the finding has been discounted
iv) the reasoning underlying why, where findings are susceptible of alternative explanations, one explanation is favoured
v) the reasoning that supports conclusions, detailing all material drawn upon to support that reasoning, including reference to pertinent and current literature
vi) all samples that have been retained by the pathologist
b) comply with the requirement that the taking of samples at autopsy, the findings of the post mortem examination and the cause of death and related issues be corroborated by a second pathologist, and that the report be signed by both
c) produce the report within the timescale agreed by contract or local service delivery agreement taking into consideration the complexity of the case. This will depend on the investigations and expertise required
d) consider additional information revealed by investigations after the provision of a report and, where necessary, produce a supplementary report incorporating that information and drawing further conclusions
e) ensure that the detail within any report reflects standards and minimum datasets contained in relevant and current guidance.
7.2 Code of practice
7.2.1 General comments
In general terms, the report or statement must be clearly laid out, section by section, in an easily read format. The following sections are recommended:
- report preamble
- history (see below)
- scene examination
- external examination
- internal examination
- supplementary findings and additional investigations (histology, etc.)
- commentary and conclusions
- cause of death
- note on retention of samples, tissues and organs and list of samples retained.
The essence of the report of an expert witness is that it should be easily read and unambiguous. The commentary or conclusions section must be intelligible and easily understood by non-medical people, so as to render it suitable for presentation in court. The report should be clearly divided into sections and, where appropriate, sub-sections. The language should be as straightforward and as simple as possible, whilst nevertheless retaining complete accuracy and balance and being sufficiently detailed to allow other medical experts to fully comprehend the abnormality or injury being described.
It should be remembered that decisions with serious legal implications may be based partly, or even solely, on the pathologist's report. It must be sufficiently detailed to allow these decisions to be made. In view of this, it must be written in a fair and impartial manner, having taken into account all the relevant issues of the case.
7.2.2 Report preamble
The report preamble must set out the full name, age, etc. of the deceased, together with the date, time and place of the autopsy. The pathologist's name, qualifications and appointment must be stated.
In order to properly identify all the circumstances surrounding the autopsy, the report should also include the names of:
- the Procurator Fiscal on whose instructions the autopsy is being performed
- the persons identifying the body to the pathologist.
7.2.3 History
The pathologist should record and may wish to summarise in their report the information that they were given before the autopsy was performed, and should identify the sources of such information. The inclusion of background information, such as the deceased's duration in hospital and/or the treatment given prior to death, can be of considerable assistance to those reading the report, whether lawyers preparing a case for court or medical colleagues who may be asked to comment.
Much of this information is likely to have been provided to the pathologist during their initial briefing; it will also come from the deceased's medical history. Proper recording of this information is essential and reference should be made to section 4, 'The briefing', and paragraph 5.2.3, 'Importance of notes', above.
7.2.4 The scene of the death
The record of the scene visit must include a note of the date and time of arrival at the scene, a note of the location and a general description of the locus and the body and should state which pathologist(s) attended at the scene.
A note must be made of recordings taken ( e.g. environmental and body temperatures) and of any samples, etc. taken prior to removal of the body.
7.2.5 External appearance of the body
It should commence with a note of the state of the body as received in the mortuary and a description of the presence of any bloodstaining, etc. An inventory must be made of the clothing as it is removed from the body. Within this section should be a note of the height, weight and build of the individual. The presence and extent of rigor mortis should be tested for and noted if relevant. The position of hypostasis should be recorded.
Mention should be made of the hair, eyes, ears, nose, mouth, scars, tattoos, fingernails, etc., even if these are normal. Negative findings, e.g. the absence of petechiae in various parts of the face in suspected strangulation, are just as significant as positive ones.
7.2.6 Injuries
Injuries, no matter how trivial, must be described in detail using recognised terms, with measurements given. The position of injuries must be described with reference to appropriate anatomical landmarks and in some instances with reference to the height above the heel. The description must include the type of injury and an indication as to whether it is of recent origin. A numerical identification system may be particularly useful where reference is to be made to specific injuries in other parts of the report. It may be helpful to record the injuries on an outline body chart, as this may assist the pathologist and others in any subsequent discussion of the case.
A separate section of the report dealing specifically with injuries is the easiest way of recording these findings, including both external and internal features. It may be best to describe the major injuries first and/or to group injuries according to type or anatomical location.
7.2.7 Internal examination
The internal examination must follow the recommendations in the College's the Guidelines on Autopsy Practice For ease of reading, the report should be divided into sections, each with an appropriate subheading.
Particular attention should be given to those organs that are diseased or injured. Also included would be the presence or absence of skeletal injuries, e.g. skull fractures. Where features out of the ordinary are found and the pathologist concludes that they are not relevant, the reasons for discounting these findings must be explained.
In addition to a full description of all the major organs, their weights should be recorded. Descriptions should be objective.
7.2.8 Supplementary examinations
Included in this section would be the results, (if available), of toxicological analyses, X-rays, neuropathology, histology and the results of any other tests or examinations that were carried out.
7.2.9 Commentary and conclusions
In this section, the pathologist should attempt to explain in easily understood language the cause and mechanism of death, as well as other relevant findings. This must be set out clearly and in a comprehensive manner to allow interpretation of the information by the police and Procurator Fiscal. The opinions expressed must be fair and unbiased and under no circumstances should be written to assist one side rather than the other. No information that may have a significant bearing on the death should be excluded, for instance in order to shorten or simplify the report. When giving opinion, the pathologist must state clearly where that opinion is based on their own work and where it relies heavily on the work, pathological findings, test results, etc. of others.
A good, well thought out commentary will be invaluable in many circumstances in allowing the Crown Office to decide whether to proceed with a prosecution. This may have significant ramifications, e.g. in facilitating the release of a prisoner in custody or preventing a potential miscarriage of justice. There may also be financial implications if a decision is taken not to proceed with a case.
Where relevant, comments should include details such as the amount of force likely to have been used, the type of weapon, the direction of injuries and the probable rapidity of death. In circumstances in which an assessment of the likely time of death is required, it must be given with adequate and defensible margins.
The conclusions reached following an examination should be clearly set out in the report giving the reasons for reaching these conclusions. It is also necessary to give some indication of the reliability of such conclusions, and possible alternate explanations or opinions should also be given. Where features out of the ordinary are found and the pathologist concludes that they are not relevant, the reasons for discounting these findings must be explained.
From the scientific findings, the pathologist may be able to construct a picture of the sequence of events that occurred. The pathologist should clearly state the evidence and rationale on which the conclusion was based. However, the pathologist must not engage in unfounded speculation or conjecture. Should the findings suggest more than one picture of the sequence of events, then all the relevant scenarios must be stated.
7.2.10 Cause of death
This should be given in the usual manner as prescribed by the Registrar General, i.e. 1(a) .... , due to 1(b)…., II….etc. Since this system may not be familiar to lawyers and others who will read the report, it may be important to elaborate on this information, for instance in the conclusion section of the report and, if appropriate, when giving evidence in court.
If, having considered all the evidence, no cause can reasonably be found for the death, then the pathologist must record it as 'unascertained' or 'undetermined' or similar.
7.2.11 Retention of samples
The report must clearly indicate what material has been retained and submitted for further scientific examination, e.g. blood samples, swabs, etc.
It is essential to include a list of any organs, such as the brain, retained for further examination.
If no organs are retained, a simple statement to this effect in the report is necessary.
7.2.12 Final check
Before the report is signed and issued, the pathologist must check it for errors such as typographical and grammatical mistakes. Simple mistakes, such as the substitution of 'left' for 'right' or 'millimetres' for 'centimetres', may significantly alter the interpretation of a finding by the reader. Furthermore, a poorly presented report with multiple errors gives the impression of a lack of care or interest in the completion of the report and, by inference, in the conduct of the autopsy and in the interpretation of the findings.
7.2.13 Time of submission of the report
The report must be submitted to the Procurator Fiscal in accordance with contractual arrangements. In some instances, it is appropriate to submit a preliminary report, detailing as far as possible the expected timing of pending interim and final reports. If there is to be a significant hold-up, the reasons for this should be given and explained. Normally, delays should only be those occasioned by the need for time-consuming special investigations, such as toxicology, neuropathology or cardiac pathology. Routine histology should not be a reason for significant postponement of a final report. However, it is preferable that the report should be as detailed and comprehensive as possible, even if this does cause some delay in its completion. In most instances, this will be more helpful to the user than the issue of multiple supplementary reports or statements.
7.2.14 Disclosure of information
The overriding duty of the pathologist is not to mislead the Court, and to ensure that all findings are disclosed to the Procurator Fiscal. Disclosure to the defence is dealt with in Section 9.
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