Quality of examinations must improve

EDITOR,—When one of my twin sons was stillborn in London in 1992 one of the main factors in my acceptance of the painful necessity of a postmortem examination was the knowledge that it would be carried out by a dedicated neonatal pathologist. I was confident that the quality of the examination would be such that any ascertainable cause of his unexpected and inexplicable death would be discovered.

Patrick H T Cartlidge and colleagues report that the main reason for the low rate of perinatal postmortem examinations is parental refusal, followed by failure of clinicians to request an examination.1 In their study almost half of the examinations failed to reach the minimum acceptable score and “information giving parents and clinicians a better understanding of the cause of death” was obtained in only 18% of cases. I would suggest that many bereaved parents would be even more likely to refuse consent if they knew these results. Furthermore, some clinicians might be less likely to request a necropsy or attempt to persuade ambivalent parents to give consent.

A higher rate of perinatal postmortem examinations is necessary for all the reasons given by Cartlidge and colleagues. But surely the first step in achieving this is to take active measures to improve the quality of the examinations through training and audit. Yet this issue is barely addressed by either Cartlidge and colleagues or Malcolm Chiswick in his editorial.2 Instead their solutions focus on exhorting clinicians to have a more positive attitude. Such an attitude will come about when clinicians and parents are persuaded that no stone will be left unturned in the search for the cause of death. In the meantime, simply hoping that the guidelines of the Royal College of Pathologists will improve matters is not good enough.3