To the Editor: In late 1998, a clinical audit in the Thoracic Division of the Prince Charles Hospital found the autopsy rate was 7% of all patients who died in the Division (excluding Palliative Care) for the 12 months to September 1998. Following discussions and acknowledgement of the importance of hospital autopsy as a clinical audit tool, the Division's policy to consider an autopsy in all patients who died was reinforced. Registrars were educated in seeking approval and in counselling relatives.

As a result of these interventions and ongoing audit, a decision in relation to autopsy is now recorded in more than 90% of charts following a patient's death, compared with 40% initially. The autopsy rate progressively increased, and, from March 2000 to January 2001, it was 35%, five times the baseline rate, and the refusal rate was 11% (Box). The rate of limited autopsies (generally only excluding the brain) increased from 20% to 50%.

However, from early 2001, coinciding with the ongoing negative Australian press coverage related to aspects of autopsies, there has been a marked decrease in relatives' agreement to allow autopsy and extent of autopsy. The refusal rate for autopsy increased to 30% for the four months to May 2001, and was 25% to September 2001. The autopsy rate fell dramatically to 27% and 13% for the same periods. Nine of the 10 autopsies were limited, usually to a single organ or body cavity.

Data from death certificates are vital for education, research and public health purposes.1,2 Autopsies remain the only way to audit the accuracy of death certificates. A review found that the rate of clinical diagnostic inaccuracy for major findings at autopsy is about a third, and this rate has not changed since 1912.3 This unavoidable baseline of diagnostic error4 does not necessarily indicate incompetence or malpractice. It is essential that the public understand that medicine is not an exact science, that we do misdiagnose conditions, and that identification of these "errors" is of value to relatives, to future patients and to society.

Legislative changes are being proposed in Australia that will make obtaining consent for autopsies more complex and potentially distressing for relatives. Education of medical staff and the general public must accompany these changes if they are not to be the final "nail in the coffin" of the hospital autopsy and remove an important facet of continuing improvement of medical practice.

Autopsy rates in the Thoracic Division of the Prince Charles Hospital