Gemma Best MAAPT reports on the morning session at AAPT Conference 2014
This year the AAPT hosted their 10th annual conference at the Copthorne Hotel in Newcastle. Our thanks go to Lydia Judge-Kronis, Michelle Lancaster, Christian Burt and David Scott for continuing to make this event such a success.
The event was opened by Ishbel Gall AAPT Chair, announcing this being the first year of the Best Practice poster competition. Three entries were received which would be judged during the event, the prize being a shield engraved with the winner’s name and a free place at next year’s conference.
It is anticipated there will be many more entries next year with particular interest in Forensic work, Toxicology and the history of Anatomical Pathology Technology.
Ishbel also took the chance to thank trade attendees for their support at the event and continued support of our association.
Alison Anderson MBE FAAPT chaired the morning session, welcoming Dr Pravat Bhattacharyya whom has worked for the HTA since 2009 as a regulation manager and is a member of the PM sector notification of HTARI’s team.
Sharing and learning – HTA Reportable Incidents
Dr Bhattacharyya gave a very interesting and essential talk on incident reporting in the PM sector.
We were informed the Histopathology PM working group consisting of members from the AAPT, RCPath, the Coroners society, the Home Office, BMA and the IBMS meet six monthly to discuss trends in HTARI’s and categories under which we should report.
The many different HTARI categories were explained to remind us of any incident we should report, due to the nature of our work these incidents may not be caused by ourselves but indeed also by other staff having access to the mortuary e.g. porters, chaplains and funeral directors.
During 2013 there were 113 incidents reported to the HTA, this was a higher figure than the 2012 figure. This increase seems to be due to staff becoming more informed of the process and understanding incidents which come under the HTARI categories.
The 2012 figure of 75 reported incidents was from a death rate of 500,000, which is very low indeed. As a profession we are very conscientious of the distress caused to families if mistakes do happen. But reporting of these incidents make for a learning curve and preventative measures to be put in place. Trends are then looked at by the PM sector working group, ensuring root causes are looked at and if need be, procedures changed preventing further occurrences.
Educate not just ourselves as APTs: educate those we work with
We were also reminded it’s not just ourselves we should be educating but also other service providers accessing the mortuary. Incidents may occur when correct training has not been given. Porters for instance have a high staff turnover and may lack the correct supervision. It is essential there is a regular training package in situ, which must include use of equipment, correct and dignified body handling, dignity and respect of the deceased, security of the department and how to report incidents which may occur out of hours. This being extremely important due to many trusts employing porters through outside agencies rather than the trust itself, porters may not have access to the trust internal incident reporting system.
Laminated step-by-step procedures
As a failsafe, an idea put forward by Dr Bhattacharyya was to have laminated step by step procedures on admittance and viewing of the deceased in a prominent position within the mortuary for portering staff to refer to. Competency assessments and audits must be carried out on all staff accessing the department. The HTA has produced a sharing learning document, providing lessons learnt from HTA reportable incidents in the post mortem sector 2012/2013.
What do Toxicologists actually do?
Next to present to conference delegates was Dr Nigel Brown from Wansbeck General Hospital.
As APT’s we are very adept at collecting samples for Toxicology, but what happens after we have sent them away to toxicology labs is a mystery! Dr Nigel Brown was here to explain exactly what does happen once they are received in the laboratory.
Many samples we sent for toxicology testing are from patients deceased due to overdose of either alcohol or illicit drugs or even due to cause unknown. The results received can be used to determine the cause of death, which drugs may have been taken and how they could have affected the state of mind of the patient before death (this being especially important to determine whether death could be decided at inquest to be accidental/misadventure or suicide). Samples can also be tested to determine whether prescribed medication has been used correctly. Accidental overdoses on prescribed medication do occur as do deaths due to medication not being taken correctly, in diabetic and epileptic patients for instance.
Drug levels may differ post mortem due to re-distribution and drugs being taken up by cells within the body. It is essential therefore to provide as much information as possible to the toxicologists, as knowing time of death can help determine drug levels at time of death.
Preferred practice would be to send admission bloods, as they would not be affected by interventions during care of the patient. Other sites of samples taken would be the femoral vein, urine if the bladder has not been compromised as this contains less lipids and protein which can interfere with the analysis and vitreous as this is more resistant to degregation, gastric contents should really only be sent if tablets are present.
The increase of legal highs
Due to one legal high entering the market every week, toxicology analysis is ever changing. Dr Brown explained the many different tests involved in toxicology including GC Mass spectrometry – the cost for which unfortunately is extremely high, liquid chromatography which is water based and used due to the cost being considerably lower. This gives an idea of which group of drugs has been taken, the usual suspects being morphine, tramadol and diazepam.
Drug testing time can vary from case to case. If the laboratory is in the same building as the mortuary and drugs consumed known, confirmation and concentration levels can be confirmed overnight. But other drug analysis tests require a standard, which are only available as a controlled substance in the U.S and may take 2-3 months to arrive.
After the thorough and informative explanations given by Dr Brown, we were shown case studies, guiding us through clues to look out for during post mortem examinations, patient history and also informed to be aware of patients treated before being admitted to hospital.
Coffee break provided us with a chance to peruse the trade stands and talk to representatives of each company. Alison Anderson then introduced Dr Nigel Cooper from Royal Victoria Infirmary.
This subject which we have all witnessed within our professional work is secretive and taboo due to its nature. Dr Cooper was here to enlighten us on the different elements of sexual asphyxia and the somewhat bizarre feelings behind it.
Sexual gratification due to asphyxia is a centuries old practice first documented in the 1740’s in regards to the Marquis de Sade. Participants are usually male and this is mainly a solitary activity although not always.
Due to the nature of this activity, details can cause great embarrassment to loved ones of the deceased, but thorough examination of the scene of death must take place to decide whether the cause of death was homicide, accident or suicide. Unfortunately post mortem will offer no assistance other than to give cause of death not mode of death.
A scene disguised
Quite often the scene will be disguised by relatives before police arrive to examine the scene, hiding the evidence of sexual behaviour of the death. Often found during the examination would be pornographic material, mirrors, bondage apparatus restricting the deceased movements and possibly evidence of cross dressing.
Understanding the practice is very difficult to most. Dr Brown explained it is used to heighten sexual pleasure, involving elements of self-protection and escape mechanisms but invariably due to loss of consciousness at between 12-15 seconds, the mechanisms fail.
A solo activity or are there others present?
The most important question at the scene is “was one person capable of the setup”? Which many times have been copied and trialled by the person investigating…much to the confusion of colleagues I should imagine!
The body itself is checked for any evidence of assault i.e. bruising, to rule out homicide. During post mortem toxicology testing is very useful as there are certain drugs which can be associated with heightened gratification and there may also be increased alcohol levels.
We were shown some graphic but mystifying photographs of these situations with Dr Brown explaining the escape mechanisms in each, and also where the plan went wrong. The greatest difference between sexual asphyxia and suicide seems to be, in sexual asphyxia the noose is very often padded and soft, as opposed to the coarse rope or belting often used in suicide. These patients have not been attempting to harm themselves but in fact cause themselves greater pleasure. This was a fascinating. interesting and sometimes light hearted explanation of a still secretive, dark and mystifying practice.
The final presentation of the morning was given by Mrs Daisy Shale CSci FIBMS Senior Medical Examiners officer from Sheffield.
A Day in the life (or death) of the Medical Examiner’s office
Daisy’s presentation brought us up to date with the reforms in death certification and the medical examiner’s role. Our present system is essentially outdated, we are still using the same practice as 150yrs ago. But we are now on the brink of change, and preparing to unify burial and cremation regulations.
Shipman...not a one off
In light of the Shipman enquiry reforms were promoted, many thought the case of Harold Shipman was a one off, but in fact this malpractice and abuse of power has happened many times before and since. Most recently we have seen the Stepping Hill incident too.
These recurrences were able to happen due to lack of transparency. The Mid Staffs and Francis report have enlightened us to failings in all aspects of healthcare enabling the workforce as a whole to take a stand and be responsible for patient care.
The current system of death certification has many problems which need to be changed. The Department of Health has developed a programme to improve death certification, ensuring the correct level of scrutiny in order to prevent these occurrences happening again.At present there are many different forms and procedures in regards to death certification, quite often doctors, especially new doctors rely on advice from APT’s, Coroner’s officers and bereavement staff. Not knowing how to complete certificates or which cause of death to give. Sometimes they are completed with no discussion with the deceased family.
Avoiding unnecessary distress to the bereaved
Unfortunately this can cause great distress to them during such an emotional period. Misunderstanding of medical terminology can also cause confusion and upset. There are not enough safeguards in place to check certificates are correct before death is registered. It is estimated up to 30% have the wrong cause of death written, whilst 60% may be reasonable.
The Department of Health in response has developed a formal process with bringing into place the Medical Examiner. Medical Examiners are not forensic pathologists and do not undertake post mortems. But they are independent formally appointed and medically trained individuals. Their task will be to investigate the circumstances of death of each deceased patient. This will include an unbiased investigation through talking to attending medical staff, scrutinizing patient notes and checking treatment and drugs received. Any misdiagnosis found will be referred to the Coroner for further investigation. It is anticipated this will assist the Coroner as only the relevant cases will be referred. The Medical Examiner will also be in a position to question why possibly the patient has not been seen by a doctor during their stay or medications not given.
There are advantages to this new system. Although it won’t prevent criminal acts it will pick them up sooner, preventing another Shipman scandal. Referrals to the Coroner will remain in the same figures, useless referrals and calls for advice reduced, but relevant referrals and industrial disease referrals increased.
This new system will certainly ensure families are more informed during the process. Once the death certificate is written it will be discussed with the family whereby they are given the chance to communicate any concerns or issues they may have in regards to the care and treatment their loved one has received. Due to the increased communication with the relatives, it is anticipated the number of consented post mortems will increase over time.
This whole process will take place before the certificate is issued, preventing forms being declined by the registrar. There will be no cremation forms as this will be an all incorporated form.
Where are we now?
The Medical Examiner process has been trialled in four areas – Gloucester, Sheffield, Essex and Powys. The Department of Health has written, but not yet published, the consultation document and it is anticipated the process, once the consultation is published, wil go live in 18 months time. Meanwhile the Department of Health are to recruit and train suitable Medical Examiners and assistants.