A study of patients referred from A&E for coroners post-mortem

A review of 179 autopsies was undertaken over a 1-year period to determine if clinically useful information was obtainable from coroners post mortems performed on patients referred from the A&E department. Fifty-six patients had undergone unsuccessful resuscitation. The leading causes of death were heart disease and trauma. Discrepancies between the diagnosis made during resuscitation and the cause of death found at autopsy were revealed especially in those dying from noncardiac causes. Iatrogenic trauma from resuscitation attempts occurred in a significant number of cases. It is suggested that review of selected Coroners post mortems should be part of departmental audit, with a view to improving clinical skills.