Doctors, death certificates and reporting to coroners — room for improvement

To the Editor: The article by Neate and colleagues1 and the accompanying editorial by Cordner2 serve as a timely reminder that, despite sophisticated imaging and pathology tests, cause of death is not always clear. Neate et al found that the cause of death as stated on the death certificate required a major change in nearly half the cases reviewed.1 This has criminal and public health implications, and feedback to clinicians caring for the patient is crucial.

Our experience of referring a medically unexplained death to the coroner in New South Wales highlighted severe workforce problems in the coroners office. It took almost a year for the report to be finalised, with the delay attributed to a shortage of forensic pathologists. Supporting pathology test results were available after a week and an interim report after 1 month, which allowed the medical team who had been looking after the patient to review the care delivered and ensure there was no major system error. However, the delay of the final report caused upset for the deceased patient’s family and anxiety for the treating clinicians. There is no criticism of the pathologist involved, as the final report was rich and informative and led to a very helpful presentation at a hospital morbidity and mortality session.

Forensic pathologists provide an essential medical service and any workforce shortages affect not only the criminal system but also medical care, as the timely provision of information on cause of death has implications for the delivery of care to other patients in hospitals and the community. We are concerned that a clinically driven increase in reporting may put further strain on this important service, and we urge the coroners office to be aware of the current constraints.