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Interim Report: Removal and retention of human material
Annex A: An account of the evidence to the Inquiry on the removal and
retention of human material at post-mortem
Summary of evidence
- The Inquiry received evidence, both orally and in writing, as to
the national context in which both Coroners' post-mortems and hospital
post-mortems were conducted throughout the period of the Inquiry's Terms
of Reference, as to the particular practice in Bristol and as to the
events in Bristol once widespread retention came to public attention.
Evidence was taken, in particular, from parents, clinicians, the Coroners
Society, the Coroner for Avon, the Home Office, the Royal Colleges of
Pathologists and of Physicians and from other relevant United Bristol
Healthcare Trust ('UBHT') employees.
- In Bristol, between 1984 and 1995, 265 post-mortems were carried
out on children who died following paediatric cardiac surgery.
- Throughout the period, of the post-mortems conducted, 220 were Coroners'
post-mortems carried out at the direction of HM Coroner in order to
establish the cause of death and subject to the Coroners Rules
 ('Coroners' post-mortems');
another 45 were hospital post-mortems carried out with the consent of
parents, pursuant to the Human Tissue Act 1961, section 2(2), ('hospital
post-mortems'). Human material removed at hospital post-mortem may also
have been used for medical education and research, section 1.
- It was common practice, in Bristol and elsewhere, for human material
removed during a post-mortem to be retained for long periods of time
by pathologists. In a large number of cases, parents appear to have
been unaware of this practice.
- Once the extent of the retention of human material was made public,
many parents of the children who had been the subject of the post-mortems
were very distressed.