Medicolegal postmortem examinations in rural New South Wales. Another rural health problem

To investigate the quality of coronial postmortem examinations performed in rural New South Wales by Government Medical Officers.

We reviewed 100 cases, examining the history of the case provided by police officers, referral letters from Government Medical Officers and macroscopic reports of the postmortem findings. Tissue specimens received were correlated with histological findings.

Only 11 cases were adequately recorded. Macroscopic description was poor in 42 cases. Major deficiencies identified included illegible hand written reports, inadequate description of organ systems, incorrect description of pathological findings and incorrect formulation of cause of death. Major diagnostic errors were identified in referred tissue samples in 13 cases--most commonly, mistaking postmortem blood clot for massive pulmonary embolism. Often organs were insufficiently or incorrectly dissected.

Coronial postmortem examinations performed by Government Medical Officers in rural New South Wales are generally of a lower standard than should be accepted by the medicolegal community. These examinations should be viewed as specialist procedures and be performed by specialist pathologists only.