Wrong cause of death ‘given in a fifth of post mortem reports’
Experts warn coroner’s courts are ‘broken’ and fear another Harold Shipman could slip through the net
ONE in five post mortem reports registers the wrong cause of death, experts warn today as they declare that Britain’s coroner’s courts are “broken”.
A lack of oversight of the work of pathologists means that unscrupulous or incompetent doctors can act with impunity and deny families the truth of
what happened to their relatives.
It was warned that registering the incorrect cause of death could also prevent insurance payouts, shut down inquests and safeguarding inquiries, and even scupper police investigations.
With no proper investigation into such deaths, often of the elderly, another Harold Shipman could fall through the net, it was warned.
The failings emerged as an investigation by The Sunday Telegraph found that a discredited pathologist, Dr Michael Heath, had been allowed to continue practising despite repeated warnings of his failings in the past two decades.
Now, at least four families have complained to the regulator. They are calling for a review of all of his cases after warnings that he could have got hundreds of causes of deaths wrong.
In two cases before the General Medical Council (GMC), he recorded healthy organs that did not exist in the body.
Some of the families will never know the true cause of death as they held a funeral while waiting months for Dr Heath’s report to come through.
Amy Dickson, whose father died, and Alistair House, who lost his mother, both thought they had cremated the wrong body when they read Dr Heath’s reports into their deaths. They came forward after The Sunday Telegraph revealed that Dr Heath was still working earlier this year.
Mr House warned yesterday: “These doctors are getting paid from the public purse, and no one’s monitoring the work that they’re delivering. There needs to be some sort of review of Heath’s cases because I strongly believe that there is the potential for injustice.”
Dr Heath first made the headlines over catastrophic failings in his examination of Stuart Lubbock, who was found dead in Michael Barrymore’s pool in 2001. The controversy over that autopsy, which has been blamed for delaying the police investigation and allowing Mr Lubbock’s murderer to walk free, led to Dr Heath’s resignation from Home Office pathology in 2006 before a tribunal found against him.
Yet, despite a 20-year litany of failings, including two quashed murder convictions, the GMC allowed him to continue working for coroners across the country. It has been estimated that he could have carried out thousands of post mortem examinations in this time and could have made potentially hundreds of errors of causes of death.
At least four families, including Mrs Dickson’s and Mr House’s, complained about his actions to the regulator and strict conditions were eventually placed on his ability to practise as an investigation was carried out. These GMC investigations are ongoing.
It is understood that in at least one case a police investigation was halted because of Dr Heath’s conclusions.
In the report on Mr House’s mother, Ann, Dr Heath described a gallbladder that did not exist, missed scars from major surgery and claimed that at 7.5st she was “well nourished”.
Dr Heath admitted that he incorrectly stated he had seen a gallbladder after the discrepancies were raised at the time. “Because of the complicated surgery in this case, what I observed was clearly not the gallbladder. The important aspect of this error is that it was not a contributing factor in the cause of death,” he wrote.
Mr House hopes that by telling his story more families with concerns will come forward to the GMC and ensure Dr Heath is struck off for good if the allegations are found to be correct.
One former coroner said: “It might be that we are only looking at the tip of the iceberg. If it is established that for some time there have been serious question marks over Dr Heath’s approach then we could potentially have to revisit hundreds of inquests. It would be a very, very serious situation.”
The GMC refused to reveal under Freedom of Information laws how many complaints had been made against Dr Heath or the outcome of a public tribunal hearing against him in 2010, citing data protection rules.
This has led families to question whether it is attempting to cover its own failings. When these allegations were put to the GMC, it said it could not comment on individual cases.
Senior pathologists said that in many reports that had been reviewed Dr Heath’s findings “bear no resemblance” to the body and coroners have been repeatedly warned that he is “hopelessly incompetent”.
As a consultant pathologist he worked across the country, mainly in London and the South East, but many
‘The whole system is broken. One of the problems is there are no votes in deaths, no one in Government cares’
officials stopped using his services because of concerns.
It is understood that Waltham Forest’s coroner was among those who struck him off their list because he failed to fill in numerous death reports. Recently it is understood that only Richard Travers, the Surrey coroner, has used his services regularly. Mr Travers is said to have asked Dr Heath to carry out a third post mortem examination on a body when his original findings were heavily disputed by a second pathologist. Waltham Forest and S u r re y councils said when his services were used, Dr Heath had an “unrestricted practising certificate issued by the GMC”.
Senior pathologists warned that the issues with coroner’s courts were systemic and wider than one rogue doctor.
Sebastian Lucas, emeritus professor of pathology at King’s College London, said: “The whole system is broken. One of the reasons for that is that there are no votes in death, no one in Government cares. The most important change would be a little bit of oversight. You can’t be a bad surgeon and get away with it, but in mortuary pathology no one would necessarily know.”
In 2006, a group of pathologists and coroners reviewed thousands of autopsies for a report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and found that a quarter were “poor or unacceptable” and one in five reported the wrong cause of death. The report was referred to in a 2015 government review, which warned that ministers were missing an opportunity to fix “critical defects in the death investigation system”.
Prof Lucas said the NCEPOD findings were still true. He has “a very good bird’s eye view of what’s going on” as he works on a number of confidential inquiries, including reviewing autopsies from f all maternal deaths across England Engla and Wales.
His comments were backed by Dr Christopher Chris Milroy, a pathologist who practised practi in England for more than two decades decad before moving to Canada where wher he still works in the field. He called for Britain to implement the peer review system used in Ontario to ensure there were checks on a doctor’s work.
One problem is that pathologists are paid less than £100 for an autopsy, a lower rate than other countries, meaning there is a shortage of professionals.
Dr Heath could not be contacted for comment. His “responsible officer” with the GMC, Dr Philip Dobson, who is charged with overseeing fitness to practise, said that he was unable to communicate the allegations to him.
Dr Dobson, a cosmetic surgeon, did not respond to questions on how long he had oversight of Dr Heath’s career or what knowledge of pathology he had to be able to advise the GMC on his fitness to practise.