Independent review of forensic pathology

The Home Office, through its Pathology Delivery Board, should take the lead in developing a new protocol for engaging with families affected by a disaster involving mass fatalities. It should consult with the Chief Coroner, the National Police Chiefs' Council and the leadership of other emergency services.

The scope of the new protocol (or protocols) should include:

- Informing the family involved whether a post-mortem examination is to take place

- Giving the family the assurance that, at the earliest possible time, they will be provided with an opportunity for a face-to-face meeting where the results of the post-mortem are explained and they are able to seek clarification in plain English with technical terms deciphered

- A process for informing family members of the existence of post-mortem photographs and images, embedding real and informed consent before any such material is shared.

In developing the future arrangements, the Pathology Delivery Board should include family members affected by previous mass fatalities. This is in recognition of one of our central findings: it is the experience of bereaved families, not just the technical competence of pathologists, which calls for a fresh focus.

The Pathology Delivery Board should engage with the Ministry of Justice on how relevant information about forensic pathology can best be incorporated into the service provided by the new Independent Public Advocate (IPA), once that post has been established. In due course, the Pathology Delivery Board should engage with the Independent Public Advocate and the permanent secretariat proposed.

We are not in a position to assess this suggestion. We do feel that the comments from these two families underline the importance of seeking further improvements in how this most sensitive of issues is explained to families, both at the time when any tissue is taken and when it is subsequently retained or destroyed. In taking this forward, a key point is recognising that it is simply inappropriate to engage families over the disposal of human tissue in a way which is rushed or premature. Consideration should be given with the College of Policing over how best practice should be incorporated in future training.

In conducting a forensic post-mortem examination in a mass fatality incident where survivability is likely to be an issue, forensic pathologists should consider this as part of their examination of the body.

We therefore recommend that the Standards Committee of the Pathology Delivery Board consider this issue and amend the Code of Practice and Performance Standards for Forensic Pathology in England, Wales and Northern Ireland accordingly.

To this end, the Pathology Delivery Board should form a consultation group of key stakeholders to consider what additional measures should be included in the Code of Practice. The consultation group should include forensic pathologists, a coroner, a representative from the Royal College of Pathologists, relevant medical experts in trauma and emergency medicine, and any other experts deemed appropriate.

The remit should be to consider the minimum standard and type of cross-sectional scanning of the body, and any additional steps to be taken by the forensic pathologist at the post-mortem examination. These additional steps may in turn enhance the assessment of survivability by both the forensic pathologist and other medical experts.

The Pathology Delivery Board should consult on and develop a plan for a transition from the current model to a new team approach for forensic pathology, at least when faced with an incident involving multiple deaths. This new team approach should be implemented at a suitable point, when all the evidence is available following a post-mortem.

As a first step towards greater resilience, the number of forensic pathology trainees should be reinstated to eight from the current number of six. The pipeline of future forensic pathologists should be kept under review and the Home Secretary should be advised accordingly.

In responding in due course to this review, the Government should take the opportunity to complete its analysis of the fundamental review of the structure of the profession submitted by Professor Hutton in 2015. In the meantime, the Pathology Delivery Board should take the steps identified in Recommendations 1 to 4 above. The Pathology Delivery Board should also develop a business case for a central web-based IT system.