– The aim of this paper was, principally, to look at the coroner's post-mortem report quality regarding adult medical patients admitted to an English hospital; and to compare results with Royal College of Pathologists guidelines.
– Hospital clinical notes of adult medical patients dying in 2011 and who were referred to the coroner's office to determine the cause of death were scrutinised. Their clinical care was also reviewed.
– There needs to be a comprehensive approach to coroner's post-mortems such as routinely taking histological and microbiological specimens. Acute adult medical patient care needs to improve.
– Steps should be taken to ensure that comprehensive coroner's post-mortems are performed throughout the UK, including with routine histological and microbiological specimens examination. Additionally, closer collaboration between clinicians and pathologists needs to occur to improve emergency adult medical patient clinical care.
– The study highlights inadequacies in coroner's pathology services.
