Histopathology and the coronial non-forensic autopsy

Sebastian Lucas

Some obvious points about autopsy histopathology

• In CONSENTED AUTOPSIES, histology always taken

​

• In FORENSIC ?HOMICIDE AUTOPSIES, histology always taken

​

• In PERINATAL AUTOPSIES, histology always taken

​

• In ROUTINE CORONIAL AUTOPSIES, histology……………………..?

MoJ Coroner Stats 2022

Message: proportion of autopsied complex cases increasing

Not enough histopathology investigation (personal rate >80%)

In the old days: Prof William St Clair Symmers’ memoir from the 1940s [‘Exotica’, publ 1984]

• He took liver histology to confirm suspicion of amyloidosis in case of traumatic accidental death:
• “When the coroner spoke at last, his anger became evident in his face and speech….as he stated that microscopical examination of any part of a body under his jurisdiction, unless he had ordered it, was in contempt of his office and that he would adjourn the inquest so that he might consider whether to order the witness’s detention until the contempt had been purged – meantime the witness would be held in the custody of the coroner’s officer.
• “The witness, the pathologist, as a newcomer to the region was not aware of the coroner’s idiosyncratic view that the microscope had nothing to contribute to the findings on post-mortem examination. “
• All diagnoses could be made by naked eye alone with enough experience

AT-03-119

• Female 94yr
• Independent living
• Mild chronic renal disease of old age

​

• Rapid decline in health
• Reduced mobility
• Admitted to hospital
• Acute renal failure
• ?cause
• Died before further investigations

• Autopsy

​

• Nothing abnormal to see grossly
• Kidneys both 45gm and scarred – typical of senile nephrosclerosis

​

• Why ARF?

​

• See the histopathology

​

Kidney = intravascular B-cell lymphoma

CD20

Case

• Female 72 yrs
• Known hypertensive
• Known PLT count ~50 ?cause
• Never investigated

​

• Admitted with weakness
• Melena stool on ward
• Multi-organ failure
• Dies - ?why

Case - autopsy

• Heart 350gm @ LVH
• Coronary arteries normal and patent
• Lungs NAD
• Liver NAD
• Two small duodenal ulcers
• Old blood in bowel
• Bone marrow red

​

• Spleen 1150gm, firm pale brown, flecked with fibrous spicules

​

Case - spleen

Case - spleen

Case - spleen

Spleen = mastocytosis …..associated with duodenal ulceration

Mast cell tryptase

Giemsa

Contents

• The law and regulations
• Some relevant history

​

• Common pathologies

​

• How to manage the coronial system re tissue retention

What happened

• 1998 - 2001 – the “organ retention scandal”
• Congenital malformation hearts at Bristol – post-surgery
• Large scale fetal autopsy organ retention at Liverpool

​

• The Retained Organs Commission
• Need for new legislation and regulations
• Human Tissue Act 2004 & Human Tissue Authority
• Coroner & Justice Act 2009; Coroners (investigations) Regulations 2013

​

• Openness over what tissue is retained and why
• Next of kin involved in tissue disposal
• Downside: excessive bureaucracy for APTs and pathologists and Designated Individual overseeing all this

Coronial autopsy histology – the law and regulations

Coroner & Justice Act 2009

• No specific reference to tissues.
• Jervis 8.38: ‘It sometimes appears certain that the death as ascertained from a PME, is from a natural cause, but the pathologist desires some further time to make a toxicological, histological, bacteriological or other examination before they will be able to the give the complete and precise cause of death…..The coroner can simply await the result of further examinations, and once they have the precise cause of death, they can discontinue the investigation [without an inquest]….’

Coroners (Investigations) Regulations 2013

• Replaced Coroners Rules 1984

​

• ‘Preservation of material
• 9.  A person making a post-mortem examination shall make provision, so far as possible, for the preservation of material which in his opinion bears upon the cause of death for such period as the coroner thinks fit.’

​

Preservation or retention of material from a post-mortem examination [Regulations 2013]

14.—(1) Where a suitable practitioner conducts a post-mortem examination under section 14 and preserves or retains material which in his or her opinion relates to the cause of death or identity of the deceased, he or she must provide the coroner with written notification of that fact.

​

(2) A suitable practitioner who preserves or retains material under paragraph (1) must provide the coroner with a written notification that—

(a) identifies the material being preserved or retained; and

(b) explains why that practitioner is of the opinion set out in paragraph (1).

​

(3) A written notification under paragraph (2) may—

(a) specify the period of time for which the suitable practitioner believes the material should be preserved or retained; and

(b) specify different periods of time in relation to different preserved or retained material.

​

(4) On receiving a notification under paragraph (1), the coroner must notify the suitable practitioner of the period of time for which he or she requires the material to be preserved or retained for the purposes of fulfilling his or her functions under the 2009 Act.

​

(5) On making the notification under paragraph (4) the coroner must also notify, where known—

(a) the next of kin or personal representative of the deceased; and

(b) any other relative of the deceased who has notified the coroner of his or her desire to be represented at the post-mortem examination,

that material is being preserved or retained, the period or periods for which it is required to be preserved or retained and the options for dealing with the material under paragraph (6) once the period or periods of preservation or retention has or have expired.

​

(6) The options for dealing with material are—

(a) disposal of the material by burial, cremation or other lawful disposal by the suitable practitioner;

(b) return of the material to a person listed in sub-paragraph (a) or (b) of paragraph (5); or

(c) retention of the material with the consent of a person listed in sub-paragraph (a) or (b) of paragraph (5) for medical research or other purposes in accordance with the Human Tissue Act 2004.

Scotland regulations

• Watched the mess that E&W made

​

• All tissue retained from an autopsy is kept in archive indefinitely as part of the medical record of that patient
• NO INVOLVEMENT OF NEXT OF KIN

​

• No bureaucracy

Morbid anatomy histology

It is not like SURGICAL PATHOLOGY

​

It is GENERAL PATHOLOGY on a whole-body scale

My contention

• Autopsy histology interpretation is often more difficult than 1-2-dimensional surgical/cytology diagnostic biopsy interpretation.

​

• Integration of multi-organ pathologies/normal = 3-dimenstional

​

• …with clinical, chronology, imaging, laboratory data etc
• ………….and inquests, ?hospital mishaps, and family questions

Autopsy evaluations in 3-D

Multiple organs pathology

Other pathology data

Haem, micro etc

Imaging data

TIME

Evolution of disease

Clinical story

What do I see at ~215 autopsies a year?

• 34% - medical deaths in the community
• SUDDEN UNEXPECTED DEATHS
• Heart attacks, hypertension, aorta rupture
• Deep vein thrombosis and blood clots to the lung
• Diabetes
• Inherited heart conditions
• Unknown fatal cancers

​

​

What do I see at ~215 autopsies a year?

​

• 20% - medical deaths in hospitals and care homes
• Peri-operative complications & pneumonias
• Dementia and old age frailty – care homes
• Cancers
• Intractable diseases

​

What do I see

• 8% - alcohol-related deaths
• Drunkenness etc
• Homeless deaths

​

• 9% - drug toxicity
• Illicit/illegal drugs
• Cocaine, morphine, opioids, ecstasy, GHB, fentanyl patches, new synthetic substances,
• Medical drugs

​

• Pathologists totally dependent on expert toxicology analytic laboratories

What do I see – more depressing

• 10%
• Hanging suicides
• Trauma, fire, drowning
• RTCs
• Train collision suicides

​

• Morbid obesity

​

• Decomposed bodies
• Usually undiagnosable

​

What do I see – niche interests

• 6% - maternal death

​

• 4% - HIV-related

​

• 3% - Sickle cell disease

​

• 4% - COVID-19

​

• 2% - Epilepsy

​

Solid airless lung in COVID-19 disease

Pulmonary thromboembolism

Calf muscle deep vein thrombosis –��real or post-mortem? ��old or recent?��Does this matter?

Lines of Zahn – alternate blood RBC & thrombus

Not true DVT – just a mass of RBC

Outcomes of thrombosis

• Organisation
• - reparative process
• - growth of fibroblasts and capillary proliferation (similar to granulation tissue), which result in the attachment of the thrombus to the vessel wall

DVT - �No attachment or organisation at intima-clot interface = acute thrombosis

Ongoing DVT – organisation��= ongoing, some days

Acute fatal PE��No organisation

Lung PE - chronic organisation = old process

Medicolegal aspects of fatal DVT & VTE

Issues

• When did the process start?
• Was the death instant or delayed?
• Could/should the DVT have been prevented by prophylaxis

Maternal VTE

• Risk factors:
• Pregnancy thrombophilia
• ?inherited thrombophilia
• Obesity
• Large uterus pressing on left iliac vein in pelvis

Evaluation of the chronology of VTE is most useful

DVT & VTE at autopsy

Analytics

• Clotting blood tests – NOT POSSIBLE ON AUTOPSY BLOOD

​

• Thrombocytosis – BONE MARROW MEGAKARYOCYTE quantitation

​

• Genetic inherited thrombophilia? Factor V Leiden etc
• SPLEEN DNA sequencing
• How to interpret any results?

Drug effects

• Thrombophilic side effects:
• OCP
• New psychotropic medications
• Clozapine

​

• Clot busting thrombolytics
• Acute resolution of massive pulmonary thromboembolism?

‘Pneumonia’ – an imprecise blanket term

• Bacterial
• Lobar pneumonia
• Bronchopneumonia
• Other

​

• Interstitial pneumonitis
• Acute lung injury
• Influenzas and coronaviruses
• UIP - usual
• NSIP – non-specific
• Fibrosing alveolitis

• Organising pneumonias

​

• Aspiration pneumonia

​

• Bronchiectasis

Pneumococcal pneumonia

Gram+ve diplococci (Str.pneumoniae)

A better Case…………

• Male 38yr, gay
• HIV-1 diagnosed Feb 2007 – pt request
• Current CD4 = 400, VL = 44,257
• Not on anti-retroviral therapy.
• Working, well

​

• Found dead at home early Jan 2008

Diagnostic gross appearance….

Acute meningitis

Gram+ve diplococci

COPD – emphysema – asthma?

Asthma:�clinically over-diagnosed.��In the elderly, it is usually emphysema

��Hyper-inflated lungs��Bronchiole constriction��Thickened basement membrane��Muscle hypertrophy��Eosinophil-rich luminal inflammation��Charcot-Leyden crystals

F 53yr, known IVDU, heroin dependent, brought dead in van to A&E by her family

• Histology taken:
• yes No of blocks = 12

​

• Organs retained: no

​

• Other samples taken: blood & vitreous to toxicology lab

​

​

• 1a. Methadone toxicity

​

• Histology results:
• BRAIN – normal; no meningoencephalitis, or hypoxic neurone damage
• HEART – RV normal; LV normal, with no acute ischaemic lesions or old scarring; a very atherosclerotic LAD coronary artery in the pericardium
• LUNG – severe emphysema, much IV injected foreign spicular material; aspirated food in airways; no acute inflammation. CPR fat embolism in pulmonary arteries.
• LIVER – normal; no steatosis, hepatitis or fibrosis
• KIDNEY – arteriosclerosis and glomerular loss; no diabetic or hypertensive changes

​

If you are taking toxicology samples, always take histology

What do you do if the tox comes back negative?

Unresolved non-uniformity in diagnostic coronial requirements

• Do you want A cause of death?

​

• Or THE cause of death?

​

​

• The more histology, the more accurate the cause of death

• Cause of death on the balance of probability?

​

​

• Or the true cause of death?

One reason for pathologists stopping coronial autopsy work – or never starting – is difficulty in obtaining permission to examine histology from an autopsy

How do you learn autopsy histopathology?

• Text books
• Ask a colleague
• Share cases

​

• Even in the most obvious pathology, you need to know what happens at the microscopic level
• Dissection of aorta
• Ischaemic heart disease
• AAA rupture

​

• Each diagnosis therefore needs to be checked the first time (at least)

Fall back position

• Withhold the cause of death
• Say you do not know

​

• Many jurisdictions have report form tick boxes:
• Samples taken to establish cause of death
• Samples taken to confirm cause of death

​

• Coroner is then stuck

What to sample?

• Depends on case and circumstances of death

​

• In a grossly negative autopsy, the 5 main organs:
• BRAIN
• HEART
• LUNGS
• LIVER
• KIDNEY

Grades and Fees of coronial autopsy

STANDARD – usually no investigations, gross examination and a cause of death

​

SPECIAL – needs ‘special skills’ and histopathology, +/- toxicology

​

FORENSIC CASES - ?homicide etc

Done by specialist forensic pathologists on Home Office Register

• Fee = £96.80p

​

​

​

• Fee = £276.90 +/- histology fees

​

​

• Fee = ~ £2-3000

Coroners (Investigation) Regulations 2013

• Histopathology fee chargable
• £35 per block, up to maximum £319 [sic]

​

• Charge true number of blocks?

​

• Or the number that critically made a diagnosis?

• Many coroners discourage histology – cost, time, bureaucracy

​

• Many coroners encourage histology charging
• As a means of increasing the autopsy fee rates
• Unchanged since 2004

You have to get to know how your local coroner operates

Regular discussion with pathologists?

Does she/he want accurate causes of death?

Does she/he respect the pathologists?