1. Providing post-mortem imaging as an NHS service

2. Or “why should every “investigative” mortuary have a CT scanner?

3. Leicester Timeline Started scanning in 2002
Mainly forensics and trauma
THE ADJUVANT SETTING
CT scan for all cases
Prevents mistakes
Provides a lasting record
Provides a simple ‘ sterile’ way of demonstrating findings

4. Death investigation Who? When? Where? How? – and by what means
Imaging may have a role in all these aspects

5. Identification Basic ‘human right’ to be identified in death
Unknown body
DVI – disaster victim identification
Anthropology

6. Fall from a height Did they fall or were they pushed / thrown?
Fracture pattern consistent?

7. Support proposed scenario

8. PMCT – targets investigation quickly

9. Scenario Car Driver Witnessed collision No previous health problems
No signs of life
No obvious injury

10. Atlanto-occipital dissociation

11. Cervical spine Easier on CT than autopsy

12. ADJUVANT: Adding PMCT to autopsy is the new gold standard
Radiology Jul;288(1):
Postmortem CT Angiography Compared with Autopsy: A Forensic Multicenter Study.
Grabherr S, Heinemann A, Vogel H, Rutty G, Morgan B, Woźniak K, Dedouit F, Fischer F, Lochner S, Wittig H, Guglielmi G, Eplinius F, Michaud K, Palmiere C, Chevallier C, Mangin P, Grimm JM.
Leicester contribute 50 patients to a pan-European 500 patient study

13. Fortunately
Traumatic and ‘suspicious’ deaths are not frequent enough to justify the expense of a CT scanner
Unless they were to be investigated more centrally
But what if we used imaging for all deaths?
Imaging now has to be a replacement

14. Scenario 2 82 year old independent female in reasonable health
Becomes unwell in the presence of her family
Acute extremely severe headache
“worst I have ever had”
Then collapsed
Unconscious on arrival in ED and then died

15. Scenario 2: CT gives a clear cause of death

16. Scenario 3 Young adult Asian patient
Dropped of at home after day at work
PMH: recent “asthma” and mild neck pain
Found dead on living room floor next morning
External exam reveals neck lymphadenopathy

17. Autopsy result: Pulmonary TB
Neck nodes
Pulmonary TB

18. PMCT – still TB

19. Scenario 4 – medical audit
Admitted after a fall
Swollen leg – ultrasound inconclusive
Anticoagulated for ? DVT
Deteriorated with lowering Hb
ECG abnormal but non specific

20. Scenario 4 – medical audit
Assumed cause of death:
1a.Ischaemic heart disease
1b Anaemia and hypovolemia
1c Haemorrhagic gastritis due to Aspirin

21. Final cause of death
1a.Ischaemic Heart Disease
1b Anaemia and hypovolemia
1c bleeding from left shoulder (#)
Haematoma at least 1 litre

22. PMCT is really good at trauma
But can it diagnose cause of death from natural causes?
Especially Cardiovascular disease?

23. Embalming

24. Ruptured aneurism

25. Targeted coronary angiography
Targeted angiography at Leicester: Double contrast

26. Scenario 5 57 male “Overweight & unfit” Recently took up cycling
Found dead next to bicycle on side of road

27. Trauma
External OK
PMCT OK

29. Why imaging as a replacement
A non or minimally invasive autopsy is preferable to the public
There is a serious workforce problem in “autopsy” trained pathologists
This is different to the radiology workforce crisis

30. PMCT has been shown to be able to deliver an acceptably accurate cause of death in most cases of adult unexpected but “non-suspicious” deaths (90%)
Lancet Jul 8;390(10090): doi: /S (17) Epub 2017 May 24.
Diagnostic accuracy of post-mortem CT with targeted coronary angiography versus autopsy for coroner-requested post-mortem investigations: a prospective, masked, comparison study.
Rutty GN, Morgan B, Robinson C, Raj V, Pakkal M, Amoroso J, Visser T, Saunders S, Biggs M, Hollingbury F, McGregor A, West K, Richards C, Brown L, Harrison R, Hew R.

31. What do we do?
Autopsy Vs. PMCT Vs. Nothing?

32. Focus on England and Wales coroners statistics 2017
530,000 deaths
230,000 (43%) reported to HM coroners
85,600 autopsies performed
16% of all deaths 37% of reported cases
61% in 1995 !!!

33. Focus on England and Wales 85,600 autopsies
Most of these are adult unexpected but “non- suspicious” deaths
In some cases these are part of a wider investigation…….
…… but in the majority they are to establish the “cause of death” …..

34. Role of PMCT – 2017 – its happening
1,671 post-mortems conducted using imaging – mainly PMCT
up from 764 cases in 2016.
56 of the 89 coroner areas in England and Wales carried out at least one less-invasive post- mortem
2018: iGene, Preston & Leicester = 4,500

35. The “integrated” Leicester Team
Community
Hospital
The HM Coroner (s)
Coroner’s Officers
Local authority
Other local interest groups
The wider region
Undertakers
Pathologist
Mortuary staff (APT)
Radiologists
Radiographers and assistants
Relevant management
Hospital board
Imaging and pathology
All have different aims, time, performance indices, job & financial pressures

36. What are we doing in Leicester
Up to 3 cases per day have CT scan instead of autopsy
Nearly every scan involves a direct change in management – no autopsy
For those that have autopsy the autopsy is often “limited”
Leicester teams have trained teams in Preston, Lancashire
Full switch to PMCT first line for all deaths

37. How does change in Lancashire service effect medical statistics
May 2017 (N-148)
Cardiac 57 (38.5%)
Pneumonia 17 (11.5%)
Overdose 9 ( 6.1%)
Hanging 8 ( 5.4%)
PE 8 (5.4%)
Liver disease 5 (3.4%)
COAD 4 (2.7%)
Cerebral infarct 4 (2.7%)
May 2018 (N-114)
Cardiac 50 ( 44%)
Awaiting Tox 16 (14%)
Pneumonia 11 (9.6%)
Hanging 6 (5.3%)
Mets 5 (4.4%)
No COD 4 (3.5%)
Aortic aneurysm 3 (2.6%)
Intracerebral bleed 3 (2.6%)
We have similar numbers in terms of cardiac causes of death (CTPM slightly higher), similar pneumonia. Some of the PE will be in the no cause of death although I suspect some are hiding in the cardiac causes.
So we are not going to dramatically alter the national statistics for causes of death

38. Scenario 6
32 year male
Found in a Leicester car park, Clearly traumatically killed
Identity uncertain

39. RICHARD III

40. Questions? Why in the NHS? Integrated service
Advantages of economy of scale
Accountability
Changing concept of looking after our patients
Extra scanner if sympathetically installed can help clinical service
Range of cases enriches medical experience – clinical practice can benefit

41. Questions? How much does it cost? How many CT scanners do we need?
Few compared to the numbers in existence
Leicester scanned approx. 80,000 CT scans in the last year
Approx. 40,000 in 2008
How many trained radiologists / radiographers do we need?
Few compared to the numbers available