During COVID (for current purposes, let’s play along with the notion that COVID is ‘over’), we became normalised to mortality statistics and the language of ‘excess deaths’. This latter term, which refers to the number of deaths above the five-year average, tells a numerical story of who is dying, as well as where, when, and how they are doing so. You can find the most recent figures, which cover the period up to June 2022 here: Excess Mortality June 2022
What these statistics do not is expose the human stories behind the facts and figures: the experiences of the bereaved, the distress and exhaustion of health care workers and, of course, systemic (or/and other) failings which led to these deaths. It is, in short, important data but which needs to be placed within its social, political, and individual context.
Outside of pandemic conditions, we would usually expect to see increased mortality over the winter. For this reason, we have a separate measure in the form of excess winter mortality index (EWMI). The December to March period is where we typically see spikes in influenza respiratory type infections, combined with increased indoor mixing and cold conditions (which of course are related). We might therefore not be surprised to see a story breaking on sky news on 29th December 2022 with the opening paragraph that: ‘Due to a high number of excess deaths in 2022, pathologists are struggling to cope with the “constant onslaught” of demand of carrying out vital post-mortems so bodies can be released to loved ones for funeral services.’ (see the full story here: Sky news shortage of pathologists story)
If we move beyond the numbers, this is a story highlighting the people behind the numbers: the people who have died, the bereaved, the doctors, those who care for the deceased body whether that be in mortuaries or funeral homes. It also hints at the uncomfortable relationship between the need for accurate information about why people die and the impact of this on those who live the consequences of it. The article refers to a ‘grief crisis’ caused by the delay in release of bodies caused by a backlog in post-mortems. It links this to autopsy pathologists priortising diagnostic work on the living. This may be true, but it is a bit of a red herring. As the article briefly mentions, most pathologists who carry out autopsy work do so in addition to their ordinary, very busy, jobs. It is, for the majority, private work carried out under ‘time shifting’ i.e., they still must complete their normal hours, with all the personal and social consequences of taking on additional work. What it does not identify is the dwindling number of pathologists willing to carry out this work. There is therefore a resource shortage double whammy – the people with the relevant skills must priortise their work with the living (and there is still a COVID linked backlog there) plus this is optional additional work which most choose not to be involved with.
In my research into the autopsy stage of medico-legal death investigation, the shortage of pathologists was highlighted by every person I spoke to. The reasons for this shortage – which was routinely referred to as a crisis – are varied but can be linked by the following key themes:
- The fee is inadequate: the basic fee for a Coroner’s autopsy is £96.80. This is set out in the The Coroners Allowances, Fees and Expenses Regulations 2013. There are ways to increase this – payments for taking histology, the application of the additional skill payment, and just plain coronial discretion, but this depends on the individual coroner and thus is a postcode lottery. Even if simple and the pathologist experienced, an invasive post-mortem will take approximately 30 minutes, plus time reading the coroner’s officers report, writing their own report and so on. Broken down, the rate is not good, and certainly not sufficient to incentivise those otherwise disinclined. A typical sentiment from my interviews was thus: ‘…the big problem is really it is not worthwhile doing coroner’s post-mortems, that is the fundamental thing because it is not core NHS work.’
- There is a lack of recognition for the work – perhaps because it is additional. This means thar the specialist skills and expertise of those carrying out postmortems gains minimal acknowledgement.
- It is hard and often unpleasant work. Again, in the words of a pathologist: ‘… it takes a lot of determination to continue with autopsies even if you’ve qualified, knowing how to do an autopsy because it is unpleasant and smells. Often mortuaries can be horribly cold. Or overheated. You’re dealing with faeces and sputum and vomit every day. And you, you know, you feel unclean when you come out. So why would you? Why would you do an autopsy?’
- For these reasons (and more), there is a shortage of trainees choosing to learn these skills. This means that as pathologists who have carried out autopsies retire, there is no workforce in waiting to replace them.
We can see that it is not just about cancer diagnostic vs autopsies, but rather the systemic and long-standing undervaluing of, and the consequential lack of resourcing of, death investigation. This matters. Even if we only care about the living (and, for clarity, we should not only care about the living), the living are the primary casualties here. The bereaved suffer. The ability of the state understand why people are dying and to allocate resources to preventing unnecessary deaths suffers. And the people who care for the deceased suffer.
In a 2021 report following the Justice Committee Inquiry into the Coroner Service of England and Wales, the Committee acknowledged that: ‘Neither any central government department nor the NHS accepts responsibility for the supply of pathology services to the Coroner Service’ (p32). At a recent workshop that I held attended by representatives from the postmortem sector, this was consistently highlighted as the biggest single hurdle to being heard and for necessary reform to take place. The reasoning follows that without responsibility, there will be no investment in fixing a broken system. The consequences of this are significant and we need to start shouting about them – this is not just about winter and excess deaths; it is not just about pathologists wanting more money. It is about the real and increasing crisis facing this crucial work. It is about valuing the dead, but more than that it is about the living.
Dead Bodies and the Law 