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Decreasing Tissue Retention in Coronial Autopsies

NSW Health Pathology
Project Added:
1 May 2015
Last updated:
15 May 2015

Decreasing Tissue Retention in Coronial Autopsies

Summary

This project examined the issue of coronial autopsy tissue retention and implemented policies and practices that reduced the amount of tissue retained and the proportion of autopsy cases where tissue was retained, without decreasing the quality of service provided. 

Aim 

The aim of the project is to reduce the retention of tissue in stock jars by 50% within six months in coronial post-mortem examinations at the Department of Forensic Medicine Sydney.

Benefits

  • Less tissue retained and fewer stock jars used, without an appreciable increase in the number of histology slides used.
  • Decreased use of and exposure to formalin, a hazardous material.
  • Cost savings as a result of a decrease in the amount of materials used and cost of tissue disposal through cremation.
  • Increased confidence of diagnostic skills in pathologists, resulting in an overall reduced reliance on defensive medicine practices, such as unnecessary retention of tissues.

Project Status

Implementation: The initiative is ready for implementation, is currently being implemented, piloted or tested.

Background

Tissue retention at a coronial autopsy can provide important information to augment the investigation of a death for the coroner. However, societal norms and legislation requires the ‘least invasive’ procedures possible under the circumstances. The Coroners Act 2009 provides little guidance in relation to authority for tissue retention as part of the autopsy.

Retention of tissues in a stock jar as part of the coronial autopsy is an added expense, uses hazardous substances, provides no added diagnostic or forensic value in the majority of cases, and is of uncertain legality. Although there is no doubt that there is a need to retain tissues in a select group of cases, this is probably a small percentage of cases, given the variable rate of tissue retention amongst pathologists within the organisation and between forensic pathology facilities, even within NSW.

A recent audit of tissue retention and stock jar use has shown that retrieval of tissues from stock jars for further examination takes place in less than 10% of cases where a stock jar was used. There is no indication that autopsies by pathologists who have low rates of stock jar use are of poorer quality or utility than pathologists who use stock jars frequently. Despite this, an average of 185 ± 127 grams (mean 210 grams in Sydney and 140 grams in Newcastle) of tissue was retained in stock jars per case, with some pathologists retaining tissue in all cases and other pathologists retaining tissue in stock jars in less than 10% of their autopsy cases.

Implementation

  • A questionnaire was sent to all forensic pathologists to assess their opinion on the practice of tissue retention.
  • A requirement for clear, unambiguous guidance in the form of a policy document and legislative amendment to formalise the practice of tissue retention was identified.
  • It was agreed that the ability to retain stock jars should be left to the individual pathologist, dependant on circumstances relevant to the case. Tissue retention in stock jars should not be an automatic component of an autopsy.
  • Written documentation was created to reliably inform the coroner and next-of-kin that a stock jar with tissues has been retained, including information on the reasons for the retention of such tissues.

Implementation sites

  • Department of Forensic Medicine Sydney, NSW Health Pathology 

Results

  • The questionnaire sent to all forensic pathologists revealed a strong desire for maintaining the practice of stock jars in select cases (42%) or all cases (58%). No respondents were in favour of removing stock jars entirely.
  • Agreement was reached between the Office of the State Coroner, the Forensic and Analytical Science Service (FASS) Executive and forensic pathologists, that retention of small amounts of tissue in stock jars was authorised as part of the coronial autopsy as long as the retention of tissue was reasonably required for the purposes of the Coroners Act.
  • The percentage of cases where tissue was retained in stock jars decreased from 93% prior to the study, to 57% as of January 2015. 
  • The amount of tissue retained per case decreased from 210 grams prior to the study, to 162 grams as of January 2015.
  • The mean retention of tissue in stock jars per autopsy case, including cases both where a stock jar has been used and those where no stock jar has been used, decreased from 195 grams per case to 86 grams (56%).
  • To date, there has been no significant increase in the number of histology blocks and slides generated and the quality of reports does not appear to have decreased.

References

  1. Coroners Act 2009 No. 41. Retrieved 1 February 2015 from http://www.legislation.nsw.gov.au
  2. Langlois, N. The use of histology in 638 coronial post-mortem examinations of adults: an audit. Med Sci Law 2006;46:310-320.

Contact

Professor Jo Duflou
Clinical Director
Department of Forensic Medicine Sydney, NSW Health Pathology
Phone: 02 8584 7800
Email: jo.duflou@sswahs.nsw.gov.au

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