It is well recognised that hospital autopsy rates have been declining for a number of years.1 It now seems to be almost an “accepted” fact that hospital autopsies are a procedure of the past, having been bypassed by newer and more effective technologies for evaluating illness and disease states.

This is, of course, completely incorrect. Every study into autopsy practice has demonstrated the usefulness and necessity of a careful dissection after death to determine not only the true cause of death, but also the response of the patient to various treatment modalities. The autopsy is, and will always be, the ultimate audit of clinical practice.2 Following appropriately conducted autopsies, it has been consistently demonstrated that suggested clinical causes of death may be inaccurate and require correcting; unsuspected but significant conditions are often discovered; and unexpected effects of therapy and procedures may be revealed. The autopsy provides an excellent basis for teaching students the fundamentals of anatomy and the manifestations of disease. It also provides important information on the effects of newer drugs on normal as well as on diseased tissues.3-5 Given these well established facts, the obvious question is, “Why are autopsy rates in such decline?”.

Pathologists often complain that the responsibility for the alarming fall in autopsy rates rests squarely on their clinical colleagues. Clinicians’ palpable lack of interest and their obvious reluctance to ask relatives to give consent for autopsy are seen in a very unfavourable and disapproving light in the corridors of pathology departments the world over. However, it must be recognised that the lighting in many pathology departments is suboptimal, often due to their temporary or basement locations, and that such perceptions may not always be absolutely correct.

For autopsies to be meaningful, there needs to be a clear understanding of the patients’ specific clinical issues. This means that contact and discussion between the treating clinicians and the supervising/autopsy pathologist needs to occur before, often during, and certainly immediately after autopsy examination. Accur-ate dissection with photographic and written documentation of abnormalities is essential, and reports need to be issued promptly, with presentation of findings immediately after the autopsy or at least at regular weekly autopsy rounds. Provisional and final reports, with clinicopathological correlations and clear gross and microscopic descriptions, are the responsibility of the pathologist. Failure to disseminate them in a timely fashion causes both the clinician and the pathologist to lose interest in the case. Once a month, a clinicopathological conference needs to be held for general hospital medical, nursing and ancillary staff and students to review interesting cases and to answer clinical questions.6

Does any of this occur? I would suggest that it often does not, and that this lack of support of autopsy practice from within the heartland of pathology may be one of the real reasons for clinicians’ lack of interest and the fall in autopsy rates. It has been observed that hospital-based pathologists, excluding those involved in paediatric/perinatal or forensic practice, do not even seem to like autopsies. Autopsies are considered to be technically messy and physically demanding and to detract from the more “scientific” and sterile world of histological and molecular pathology. In fact, they are sometimes seen as some sort of atavistic medical throwback, to be undertaken only by second-rate academics and those who are unemployable in the real world of 21st century anatomical patho-logy! Proof of the lowly status of the autopsy can be seen in the delegation of responsibility within hospital departments. All too often, the most junior registrar with the least training in anatomical pathology is designated to perform autopsies. The autopsy may even be undertaken in the absence of a consultant. Often it is a mortuary technician — one with many years of experience but no formal training, except in the “university of life and the school of hard knocks” — who teaches the unhappy registrar autopsy techniques. Registrars complain about how difficult it is to get consultants to review cases once dissections have been completed; and yet the literature maintains, and surveys have found, that “the necropsy is an invaluable investigation which is currently under-used”7 and that “most pathologists consider autopsies to be valuable and important for quality assurance in health care”.2 However, perhaps we should judge pathologists by what they do, rather than what they are quoted as saying?

Could this be a scurrilous and unfair suggestion? Possibly. However, one way to assess the validity of these assertions would be to examine pathology department records to find out when the last time was that senior pathologists performed an autopsy examination by themselves. I would suggest that years might well run into decades. Perhaps the most impartial and unemotive way to assess this would be to use a scoring system to objectively determine a pathology department’s commitment to autopsy practice . . . And fortunately, one just happens to be available (see Box).