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Interim Report: Removal and retention of human material
Part I: Introduction
Background
Problems of language and definitions
Post-mortem examination - the two types
Consent and objection
'Removal' and 'retention'
Periods of time during which human material may
need to be retained for the purpose of a post-mortem
Statistical context
- This is an Interim Report. It is published in advance of the Inquiry's
Final Report so that it can be taken into account by the Chief Medical
Officer for England. He is currently undertaking an investigation into
organ and tissue retention in England to consider what the issues are
and what needs to be done in the longer term. He will be making a final
report to Ministers in September following which comprehensive advice
will be issued to the NHS. We commend our views to him.
Background
- We concentrate on parents[1] and their children, since they are the central concern of our Inquiry. The terms of reference of this Inquiry require us to consider the paediatric cardiac service provided at the Bristol Royal Infirmary[2] from 1984-1995. Where a child died after surgery, the treatment of the child's body after death, and treatment of the child's parents, clearly fall to be considered as part of our examination of that service. Further, it soon became evident to us that this was an issue of great and grave concern.
- The Inquiry took evidence on this issue, both written and oral, from parents of children who had undergone post-mortem examinations following paediatric cardiac surgery at Bristol, from clinicians and other professionals directly involved in that process in Bristol; and from Royal Colleges, the Coroners' Society, the Home Office and the Department of Health in relation to the national framework within which that process took place.[3]
- The issue of concern was that, without the realisation of parents,
tissue had, over a long period of time, been systematically taken at
or after post-mortems on children who had died following paediatric
cardiac surgery at Bristol. The tissue had been removed and retained
by the pathologists at the UBH/T[4]
and used for a variety of purposes, including audit, medical education
or research, or had simply been stored.
- When the practice of tissue retention came to light in Bristol, there was, both in Bristol and elsewhere, an outcry from parents. They sought information about whether tissue had been removed from their children. Once informed, some asked for organs and tissue to be returned for burial. In response, an extensive search was carried out in Bristol to discover what tissue had been removed, and once removed, what had become of it. Parents were notified and, if they wished it, their child's tissue was returned to them. Not surprisingly, given the scale of the exercise and the time period covered, mistakes were made about whether in fact tissue had or had not been removed and retained. Some parents were misinformed, only later to learn the real circumstances.[5] The additional pain and distress is a cause of the greatest concern.
- The press and other media gave considerable publicity to the evidence of Professor Anderson[6] in September 1999 in which he described the various collections of tissue which existed around the country. As a consequence, parents whose children had died in hospital (not necessarily as a consequence of paediatric cardiac surgery), sought information from the hospitals named by Professor Anderson.[7]
- In late 1999, the Secretary of State asked the Chief Medical Officer
of England to prepare an inventory of centres where tissue was held
and of the tissue retained and to review current practice with a view
to making recommendations.
Problems of language and definitions
Tissue
- There is no definition of 'organ' or 'tissue' in the relevant statutes. The word 'tissue' has come to be understood by some as a generic term including not only small sections of tissue but whole organs and parts of organs. This is not, however, how the term tissue is understood in everyday language. Indeed, most people would not regard organs as being properly described as tissue. Herein lies one of the many barriers to communication and understanding which are at the root of the problem we are examining.
- Black's Medical Dictionary defines tissue as: 'The simple elements from which the various parts and organs are found to be built... It is customary to divide the tissues into five groups: epithelial tissues, connective tissues, muscular tissues, nervous tissues and wandering corpuscles of the blood and lymph' and defines organ as:'A collection of different tissues that form a distinct structure in the body with a particular function or functions... [for example] the kidneys, brain and heart.'
- The report of the Nuffield Council on Bioethics, Human Tissue Ethical and Legal Issues, [8] took the term tissue to include: 'Organs, parts of organs, cells and tissue, sub-cellular structures and cell products, blood...'.
- To avoid the confusions associated with all other suggested definitions
we will adopt in this report our own general term, 'human material',
which includes not only tissue in its various forms, organs and parts
of organs but extends also to any other material such as amputated limbs.
We emphasise that the term 'human material' is not a legal term. (Thus,
we do not use it in Annex B, where we discuss the relevant law.)
Post-mortem examination - the two types
- When a person dies in hospital, the attending doctor completes a medical certificate of cause of death. The certificate is then taken, by parents in the case of a child, to the Registrar so as to register the death.
- As a matter of law, a Registrar is obliged to refer to the Coroner deaths which fall into a number of categories, including those where the cause of death appears to be unknown, or which appear to have occurred during an operation. In practice, in many such cases it is the doctor who contacts the Coroner's office directly. The Coroner may decide to order a post-mortem, or he may consider that there is sufficient information for a death certificate to be issued. The purpose of carrying out a Coroner's post-mortem is limited in law to establishing the cause of death of the deceased. This is considered in full in Annex B.
- There is another kind of post-mortem, known as a hospital or a consent post-mortem. The rationale, authority and legal framework for this type of post-mortem is entirely different from that for a Coroner's post-mortem. A hospital post-mortem arises for a number of reasons, one primary reason being where it would be beneficial to medical care to study the cause of death in greater detail. Such an examination may also be carried out with a view to obtaining human material for the purposes of medical education or research. Although this is often referred to as a post-mortem examination, strictly speaking it is not a post-mortem at all, but a procedure aimed at removing and retaining human material. The legal framework is not the Coroners Act 1988 (the 1988 Act) but the Human Tissue Act 1961 (the 1961 Act).
- It follows that a Coroner's post-mortem should not serve as a vehicle for a number of other medical or scientific purposes, however worthy or beneficial these may be. But, given that when a post-mortem is not requested or directed by the Coroner, the hospital must make enquiries as to whether parents object to a so-called hospital or consent post-mortem, and that such a process is inevitably distressing, it can be understood how hospitals and clinicians might wish to resort to Coroners' post-mortems for purposes which can only properly be authorised through recourse to hospital post-mortems (broadly defined).
- We emphasise again that the focus of this report is parents and their
children. In the context of post-mortems, the law is broadly no different
as between children and adults. Thus our analysis and recommendations
should be applied to all post-mortems, except wherever the law prescribes
otherwise.
Consent and objection
- If a post-mortem is requested or directed by the Coroner, he is not required by law to seek the consent, or respect the objection, of parents. In the case of a hospital post-mortem, however, the central feature of the statutory framework is that it may not be authorised if any relative objects to its taking place. The Human Tissue Act does not require that consent be given; it merely requires that there be no objection. In practice, even before the Human Tissue Act was passed, parents and relatives were commonly asked for their consent.
- In Bristol, as we shall see, when Coroners' post-mortems were carried out on the authority of the Coroner, parents were not advised of, far less asked for their views on, the fact that the pathologist might take or retain human material, nor of the uses to which the human material might be put. [9]
- Equally, in Bristol, when hospital post-mortems were carried out,
although asked whether they gave their consent, parents signed forms
which were not explicit as to what might be done.
'Removal' and 'retention'
- We take the term 'removal' to mean the short-term removal of human material from the body, and subsequent reuniting of that tissue with the body prior to its burial or cremation.
- We take the term 'retention' to mean that tissue is removed from and not immediately thereafter reunited with the body, either being retained in the short term (for further tests to be carried out), or retained in the long term (for example for educational or research purposes).
- Coroners work to a set of rules called the Coroners Rules, made under statute. A Rule of particular relevance to the issue of retention is 'Rule 9'. It states that 'A person making a post-mortem examination shall make provisions, so far as possible, for the preservation of material which in his opinion bears upon the cause of death for such period as the coroner thinks fit.'
- As we set out, during the course of the evidence taken by the Inquiry,
it became apparent that these terms were not uniformly applied, nor
indeed understood, by professionals let alone parents.
Periods of time during which human material may need to be retained for the purpose of a post-mortem
- Human material may need to be removed for examination. This is important
for parents, not least as regards the timing of the burial or cremation
of their child. Historically, it has been necessary for a pathologist
to keep at least some human material for days or even weeks so as to
allow a proper scientific examination. Over time, and particularly over
the last decade, the scientific procedures available to pathologists
have allowed many of these time periods to be significantly shortened.
Statistical context
- The Office for National Statistics supplied the following data to
the Inquiry in April 2000:
Table One:
Deaths and post-mortems, England and Wales 1984, 1990, 1995 and 1998, All agesTotal deaths
Total post-mortems:
Of which
Hospital
deaths [1]Hospital post-mortems:
Coroner's
Not at
request of
Coroner [2]Total
Coroner's
Not at
request of
Coroner [2]1984
566,881
138,071
20,833
343,467
55,746
19,367
1990
564,846
130,443
11,636
357,767
55,860
11,199
1995
569,683
124,231
n/a
309,481
55,977
n/a
1998
555,015
121,584
3,524
304,350
55,929
3,335
n/a = Not available
Notes
1 Hospital deaths for 1984 and 1990 are an aggregate of two institutional categories: NHS (non-psychiatric) and non-NHS (non-psychiatric). For 1995 and 1998 the figures are an aggregate of general hospitals, sanatoria, geriatric hospitals or units, chronic sick hospitals, maternity hospitals, military hospitals and multi-function sites.
2 A post-mortem not at the request of a Coroner is a post-mortem performed by a certified medical practitioner usually at a hospital but not always. These are the best available data nationally on hospital post-mortems.
Source - ONS: The ONS does not routinely publish all of the data above. It does publish some data relating to death certification by cause of death but not by place of death.
Table Two:
Deaths and post-mortems, England and Wales 1995 and 1998, ages 0-16Total deaths
Total post-mortems:
Of which
Hospital
deaths [1]Hospital post-mortems:
Coroner's
Not at
request of
Coroner [2]Total
Coroner's
Not at
request of
Coroner [2]1995
6,086
1,881
n/a
4,931
1,156
n/a
1998
5,622
1,645
422
4,656
1,122
416
n/a = Not available
Notes
1 Figures not available for earlier years in this format.
2 A post-mortem not at the request of a Coroner is a post-mortem performed by a certified medical practitioner usually at a hospital but not always. These are the best available data nationally on hospital post-mortems.
Source - ONS: The ONS does not routinely publish all of the data above. It does publish some data relating to death certification by cause of death but not by place of death.
The significant points to note from tables are:
- For the population as a whole, many more Coroners' post-mortems are performed than hospital post-mortems following deaths in hospital. In 1998, approximately18 per cent of hospital deaths were followed by a coroner's post-mortem, and1 per cent were followed by a hospital post-mortem.
- The number of hospital post-mortems has declined dramatically since the early 1980s for all deaths, as well as for deaths in hospital, whereas the number of Coroners' post-mortems has remained fairly constant. Between 1984 and 1998 the number of hospital post-mortems following a death in hospital fell by 83 per cent.
- While national data on deaths of children aged 16 and under is only available for recent years, the overall patterns apply - that many more Coroners' post-mortems than hospital post-mortems take place.
- It is notable that a high proportion of children who die, do so in hospital, approximately 80 per cent, compared with just over 50 per cent for the population as a whole.
Footnotes
1 Whilst we refer in this Interim Report to 'parents', we do not seek to resolve here wider questions of the exercise of parental responsibility, but refer to the general law [Return to text]
2 See Appendix for the description of the Bristol Royal Infirmary, UBHT and UBH [Return to text]
3 A list of witnesses appears in the Appendix [Return to text]
4 See Glossary in the Appendix [Return to text]
5 See Annex A for full details [Return to text]
6 See Appendix [Return to text]
7 Professor Anderson, in his evidence, said that major collections were held at Alder Hey Children's Hospital, Royal Brompton Hospital, Great Ormond Street Hospital for Sick Children, Birmingham Children's Hospital, Leeds General Infirmary, and The Freeman Hospital Newcastle, Southampton General Hospital and the Royal Manchester Children's Hospital [Pendlebury]. (see T45 p. 104-106) [Return to text]
8 April 1995 [Return to text]
9 Rule 9, Coroners Rules 1984 (The 1984 Rules), requires a pathologist conducting a coroner's post-mortem to make arrangements for preserving 'material', ie, human material, which in his opinion bears upon the cause of death. See Annex B for a full discussion [Return to text]