Autopsy is a medical procedure which is often held up as the gold standard for determining the cause of death. However, astonishingly little attention is devoted to quality assurance of the method itself, and few studies have been made. A North American study examined only the information on the front page of the reports, and concluded that standardisation was needed (14). A more detailed study of forensic autopsies from the UK concluded that the quality was poor or unacceptable in 25 % of these (15).
It is important to specify that our study does not concern the quality of how the autopsy itself is performed, it refers only to the reporting. Our review of medical autopsies shows that the majority of the reports contained adequate descriptions of the findings, but had greater deficiencies when it came to addressing the clinician's questions, causes of death and turnaround times.
A direct answer to a specific question from the requisitioner was provided in only one-third of the cases. The reason for this lack of comments on specific questions could be that the issues listed by the clinicians were regarded as standard phrases, but could also be due to the long turnaround times, with little focus on the requisitioner when the report is finally written. Most autopsies are performed within a few days, provided that the clinician has completed the request for an autopsy. The autopsy procedure takes no more than a couple of hours. The production of samples for microscopy will not necessarily take longer than for other kinds of tissue diagnostics; the specimens can be examined and the report completed within a week. The long time spans from the performance of the autopsy until the report is distributed is a well known problem internationally as well (15, 16). Our study revealed turnaround times that are well above what is recommended in the guidelines from the Norwegian Society of Pathology (DNP), which indicate turnaround times of two and eight weeks for autopsies without and with neuropathology respectively (17). Long turnaround times may testify to a lack of focus on the importance of autopsies in pathology departments, where diagnostics of samples from the living are prioritised above those from the deceased, and may also reflect a capacity problem, not least with regard to neuropathology. In a study undertaken at the University Hospital in Bergen, reorganisation of the pathology department helped reduce the turnaround times significantly (18).
The importance of autopsies has changed. From an original focus on pathological/anatomical findings, the importance of assessing findings in connection with the clinical aspects has come to be emphasised (19). In the absence of any knowledge of the patient's medical history and without including the clinical picture, many types of causes of death may be overruled in the autopsy reports, and thereby also in the cause of death statistics. Non-inclusion of clinical findings and infrequent use of supplementary examinations during autopsies may be reasons why issues such as psychiatric conditions or diabetes are frequently underreported by pathologists as underlying causes of illness and death (20). Our study also shows that little importance is placed on a significant gross finding such as obesity, despite the fact that this is a potentially lethal condition. The consequences for monitoring of public health and the obesity epidemic are obvious (21). Interdisciplinary post-mortem meetings would help ensure that relevant information is considered in the reports and contribute to better communication with the clinician.
There are no available guidelines for the use of supplementary examinations in medical autopsies. Toxicological examinations could be of particular value in cases of death with little or no clinical information. The small proportion of toxicological examinations could be due to the high costs involved (22). Lack of supplementary examinations for viruses indicates that virus-induced communicable diseases are underreported.
The autopsy reports in our study date from 2014, but no changes have been made to medical autopsy practices in Norway before or after this period. There is thus no reason to believe that the autopsy reports from 2014 fail to reflect current autopsy practice. The comparison of autopsy findings in our study with the cause of death statistics confirmed that autopsy is an important corrective to the determination of cause of death, as the coding was changed in one-half of the cases. This has also been pointed out by others (22, 23). Because difficult cases are selected when the autopsy frequency is low, the proportion of 57 % change in the cause of death coding is likely to be unnaturally high.
Close to every fifth autopsy report stated a wrong underlying cause of death. The algorithms in the WHO regulations that the Cause of Death Registry is using capture the most obvious errors in the formulation of the cause of death, and not all types of errors are therefore equally critical to the statistics (24). For instance, in our example of category 1 errors in Table 3, the algorithms would have prevented a miscoding by recognising an illogical chain from 1 c to 1 b (COPD does not cause coronary atherosclerosis). The errors nevertheless resulted in a miscoding in the statistics for nearly one-half of the faulty reports. The low autopsy frequency means that poor quality of the autopsy reports currently has little impact on the national cause of death statistics. The error rate confirms, however, that pathologists need better knowledge about reporting of findings and causes of death. A generally low number of medical autopsies has led to reduced requirements for specialist training, which may cause competence levels to drop even further (5). Medical autopsies are performed by trainees and specialists in pathology. To improve the quality, the UK has made medical autopsy a sub-specialty (25). The need for autopsy to be a separate discipline has also been proposed in the Netherlands, Germany and the United States (26–28).
Forensic autopsy reports undergo quality assurance by the Norwegian Board of Forensic Medicine (29). A similar body for medical autopsies has previously been proposed, but not established (30). Our study corroborates the continued need for systematic quality control of medical autopsy work.