The impact of the organ retention controversy on the practice of hospital necropsy: a four year audit.

Following the recent publication in this journal of two original articles dealing with the value of the necropsy and its practice after the ‘‘organ retention scandal’’, we report on the situation in Ireland, where the issue of postmortem practice is still the subject of a formal inquiry. Worldwide, there has been a considerable decline in the incidence of hospital necropsies over the past several decades. It is generally acknowledged that this consistent and pandemic decline has a complex aetiology. 14 The recent and ongoing ‘‘organ retention’’ controversy is thought to have had an important additional impact. We undertook a study to assess whether or not a significant reduction occurred in the total number of hospital necropsies (in excess of the recognised worldwide reduction) being performed in an adult hospital in the aftermath of the organ retention controversy. Our study took the form of a retrospective audit of consecutive necropsies performed (both coroner’s and ‘‘consented’’) in Beaumont Hospital, Dublin, Ireland. Data were reviewed relating to hospital deaths and necropsies for the two years preceding the revelations (1998 and 1999) and the two years after (2000 and 2001). Given the particularly sensitive and emotive nature of whole organ retention, in particular relating to hearts and brains, hospital cases were divided into those that could be considered as general house cases and those that were specifically neurological. This distinction was facilitated by virtue of the fact that Beaumont Hospital functions as the national tertiary referral centre for neurosurgery in Ireland. The overall and differential (coroner’s versus consented) necropsy rates for the years 1998–2001 were calculated. In total, necropsies were carried out on 1164 patients between 1998 and 2001 inclusive. The annual overall necropsy rate declined from 29.6% in 1998 to 25.9% in 2001, with only minor variations in the total number of hospital deaths. Analysis of differential necropsy rates during this time period revealed a dramatic reduction in the incidence of hospital postmortem examinations being conducted since 1999, dropping from 71 in 1998 to 23 by 2001. The reduction in the hospital necropsy rate was similar for both general house cases and those that were specifically neurological. The overall number of coroner’s cases remained relatively stable over the time frame of our study. There was no variation in patient age. The incidence of limited necropsy (average six requests each year) remained relatively constant throughout each year reviewed. Our findings not only complement the generally observed worldwide trend of a consistent and progressive decline in overall necropsy rates, they also strongly corroborate the prevalent belief that the so called organ retention controversy has had a significant impact on the number of hospital postmortem examinations being performed. The impetus behind such a dramatic decline is undoubtedly complex and, as a result, a multitude of explanations have been proposed. The findings of Burton and Underwood suggest that the low rate is because clinicians do not request permission for necropsies. The dramatic decline identified in hospital necropsy rates has substantial implications for future hospital necropsy practice. Not only are there profound and extreme implications for the advancement of medical research and development, the future quality of patient care is severely compromised through the failure to date to implement a valid alternative form of clinical audit. Ultimately, if the current decline in hospital necropsy rates is to be halted, time and effort need to be invested in regaining public trust and confidence so that the fundamental contribution of the hospital necropsy to medicine may continue.