News

Trainee APT visits a Digital Autopsy centre

13 November 2018

Student APT Ellen Vincent-Shaw reports on her experience visiting a centre with a digital autopsy service

During a conversation in the mortuary where I work, a colleague informed me that our coroner had given authorisation for one of our patients to be transferred to Sheffield for a digital autopsy (DA) at the request of his family. 

This term, digital autopsy intrigued me and I was confused by who in this scenario would determine the cause of death. With many questions I decided to do what anyone in search of answers would do and consult Google. My search took me to a link on the Digital Autopsy by iGene website in which the founder stated a personal tragedy involving a relative who required a post mortem played a part in his belief that non-invasive imaging is the rightful future of post mortems.

The overtone of the article seemed rather anti-traditional post mortems and the word dignified was used in conjunction with the term Digital Autopsy enough times that it seemed to suggest that invasive procedures must then be the opposite.

As a trainee APT, I worried that in the near future Digital Autopsy sites would be popping up in every city making traditional post mortems, and surely those who perform them, obsolete. I hit the contacts link and enquired about an insight visit. 

My colleague and I arrived at the facility in Sheffield and were greeted by the lady responsible for arranging our visit. Once introductions had been made we were regretfully informed that there were no scans booked yet. 

Apparently that never happens, so given that it was still early we remained optimistic that there would be a scan later on.

Meanwhile the National Digital Autopsy Services Manager - who is a trained Radiographer originally - told us of how she had come to scan deceased patients after years of scanning the living, before going on to give a thorough account of Digital Autopsy’s UK reception and some interesting information. 

• Visual post mortems have faced resistance from some pathologists and, although I cannot speak for them, I have heard a pathologist make comment of the scan’s inability to show with any certainty a range of common causes of death such as pneumonia, peritonitis, or pulmonary embolisms. However, many pathologists back the utilisation of post mortem CT scanning, with many agreeing that the gold standard of post mortems is to use the scan as a guide for invasive investigation.
• They had better reception from coroners, with the 2013 Chief coroner expressing the view that as science and technology develops, digital scanning is a valued option moving forward in order to, where possible, ascertain cause of death whilst preserving the patients intact body for the benefit of their loved ones. 
• Families of patients referred to the coroner can request a digital autopsy but ultimately it will be up to the coroner to decide if it happens. The coroner is obligated to pay up to the cost of a traditional post mortem towards the £600 price tag with the family funding the rest, unless the scan is required as part of a forensic case. In non-forensic cases where an invasive post mortem is required after a scan the cost will be refunded to families. Some local governments have shown support for Digital Autopsy by funding scans for their residents. 
• There are four current DA locations with one acting similarly to a “drive thru” - funeral directors arrive with a patient and wait whilst they are scanned.  Most provide targeted coronary angioplasty and although Sheffield doesn’t currently, it will likely be an APT that takes on this role when the time comes.
• Digital Autopsy sites are not yet governed by the HTA meaning it fell to the mortuary manager there, to report the three incidences - that have occurred in their 5 years - on their behalf.  

With this wealth of new knowledge we were shown to the room where the magic happens, the scanning suite. 

Here we met another manager and the radiographer for the day, both of which were happy to announce there was a patient to scan. The manager explained the procedure for scanning patients and mentioned that patients are scanned in body bags as this is cleaner for the machine and staff. 

They receive PM requests, containing the circumstances surrounding death as well as the patients’ previous medical histories and Digital Autopsy sorts PMs into three categories; DA (Digital Autopsy only), DA and Toxicology, and limited PM, which would likely be chest or abdomen. Rarely do patients require a full post mortem or for their heads to be examined. 

Once each scan was completed -which took all of ten minutes – the radiographer talked us through the scan images describing any notable pathology, significant findings, or non-organic materials. 

We were lucky to see a wide range of medical foreign bodies including a pacemaker, hip replacement, metal pins in a foot, and even a false eye.

The first scan we observed, the patient had collapsed in the street due to suspected drug use. There was not much to note from these images so we suspected his calcification score might provide a probable cause. Another patient was thought to have had a perforation. I was perplexed as to how this would present on a scan which led to a discussion about what the CT scanner could demonstrate and what it could only suggest the presence of. 

Fractures, tumours, haemorrhages, calcification and a pneumothorax are examples of pathology that a scan would pick up. Evidence of Epilepsy, detecting arterial occlusion, and differentiating between the presences of gas due to perforation as opposed to decomposition, is not the CT scanners forte. I was pleased to have recognised emphysema on the scan of one patient as at the time of the first scan I couldn’t even correctly point out the lungs. 

The mortuary manager then took us on a tour of the mortuary before settling us down for an APT to APT chat. I was pleased to have this chance to find out what impact DA has had on the roles of the APT’s.

I was reassured that she also found uncomfortable the implication that DA provides a more dignified PM experience compared to traditional invasive post mortems and, as she rightly pointed out, it’s the mortuary staff that clean and reconstruct any patients that are in poor conditions or involved in traumatic deaths, thus restoring dignity to patients. 

The APTs also spoke with honesty about what it was like to work alongside Digital Autopsy and how it had changed their workload. Their day starts with getting out all the patients scanned the previous day for the pathologist who, armed with the patients scan results and radiologists reports, carries out the external examinations.

They then get told which patients are DA only, meaning the pathologist is satisfied with the cause of death provided by the radiologist, which patients need toxicology, and which are to have invasive procedures. Surprisingly doing mostly limited eviscerations can take just as long as full procedures due to working from smaller incisions. As an aside to the everyday running of their public mortuary, one APT is required to be on standby each day to transfer patients to and from the CT scanner, taking a member of staff out of the PM room. 

The scans create more patient transfers too, making manual handling a bigger concern than before for the mortuary staff.   

All that being said, From an APT’s point of view, Digital Autopsy has provided opportunity for APTs to gain new skills, demonstrating that not only is the role of the APT safe, but there is room for the job to grow and adapt along with this development. It was even speculated that APTs could one day learn to operate the scanner.