In their recent study Shojania et al1 highlight the importance of necropsy to clinical care by demonstrating how diagnostic sensitivity for three conditions is overestimated without necropsy results. This study prompted an editorial by Guly calling for more research to show that increasing necropsy rates can improve patient care.2
Clearly, the evidence establishing the value of necropsy for identifying diagnostic and management issues relevant to patient care3 is not preventing the international decline in the number of hospital necropsies. We therefore support Guly's petition for more evidence and describe our efforts to improve communication between pathologists and clinicians to facilitate such research.
At the Victorian Institute of Forensic Medicine, forensic necropsies are conducted on approximately 80% of hospital deaths investigated by the Coroner's Office in Victoria, Australia.4 A significant barrier to using the lessons of forensic necropsy for the improvement of clinical care is the lack of communication channels between Coroners and clinicians. The Clinical Liaison Service, which is the medical investigation unit assisting the State Coroner's Office in Victoria, attempts to bridge the gap between Coroners and clinicians.
Established in 2002, the Clinical Liaison Service reviews the hospital care of the deaths reported to the Coroner. This unit developed a standardised review process that integrates the necropsy results with the review of medical records to identify potential system failures in clinical practice. The review process includes a multidisciplinary discussion with a Coroner, forensic pathologist, clinicians and coronial staff to determine which issues, if any, should be investigated further for the goal of system improvement and death prevention. Approximately 2000 hospital deaths have been reviewed by the Clinical Liaison Service and 25% of these have undergone review at the multidisciplinary discussion.
At the conclusion of the investigation the Coroner makes a formal legal finding that includes the issues of concern and recommendations to improve healthcare practice. As the Coroner's recommendations are not always widely distributed,5 the Clinical Liaison Service provides feedback to hospital staff to improve health professionals' understanding of cases with patient safety implications. This feedback includes face to face presentations and a synopsis of noteworthy cases in the unit's quarterly publication the Coronial Communiqué.6
As the work by Shojania et al shows, necropsy results have the capacity to impact on clinical practice far more broadly than at the individual case level alone. In Victoria a national database, the National Coroners' Information System (NCIS), has been established to provide a national repository of information about each Coroner's case including the forensic necropsy report.
It is vital that health researchers and clinicians consider the lessons from necropsy results in individual cases as well as in an aggregated form. Furthermore, their resulting information must be communicated widely or many valuable lessons may be overlooked.