One of the casualties of a highly technical approach to medicine has been the autopsy. For a variety of reasons autopsy rates in hospitals have been declining¹, and this will have an adverse effect on clinical practice. Recent controversy over the retention of organs and tissues removed at autopsy has prompted reviews of laws and practice around the country. The results and implementation of such reviews will profoundly affect the future of the autopsy. One certainty, however, is that audiences, including medical ones, are always surprised at the results of studies showing significant rates of diagnostic error in death certificates provided by clinicians². These error rates, contrary to conventional wisdom, have not declined in line with improved access to sophisticated diagnostic and imaging technology. In reality this is not all that remarkable, because the clinical diagnosis of the cause of death is based on evaluation of the clinical features and course of the disease; the death itself is usually not observed, a physical examination is not possible and the results of the relevant special investigation, an autopsy, are not available. One corollary of this is important: a doctor should not feel that a mistaken cause of death revealed by autopsy is necessarily a criticism - arriving at causes of death clinically is an inherently flawed process.

On this ground alone, an autopsy should be considered following the death of every patient. This will often involve the clinician or another suitably qualified or experienced person providing all the requisite information prior to seeking the consent of those required by law. Such information provision should include discussion of the need for, or desirability of, retaining organs and tissues for further assessment or other proper and agreed purposes (eg, education, research). In any event, hospital procedures should be meticulously observed in this area. Even where there is refusal for autopsy, the very fact that permission has been sought may be important for relatives as it demonstrates a continuing interest and indicates that even in death there may be something to be learnt. The approach also gives relatives an opportunity to be involved and to exert some control over the situation and this can be valuable.

If permission is given and the autopsy is performed, there are a number of benefits:

Before a clinician rejects the idea of an autopsy, it should be remembered that in 20-30% of cases where there is no autopsy, the major underlying cause of death given by that clinician will be wrong. In about 10% of hospital deaths, the clinical diagnosis of the cause of death will be such that, if the correct diagnosis had been made, different management might have altered the outcome³. The practice of medicine is based upon continued learning and the accrual of valid experience - without an autopsy a clinician cannot know whether the diagnoses made were correct and the management provided was appropriate. An autopsy not performed means that an opportunity has been missed to confirm or improve clinical practice.

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