Recurring concern
Unreliable coronial autopsy governance and processes
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Request correctionFirst reported 20 Jun 2019•Latest report 25 Nov 2025
What this concern includes
Includes failures in explicitly coronial autopsy or post-mortem governance and processes, including outdated protocols, failure to incorporate relevant scientific developments, inadequate independent peer review, and other dedicated quality-assurance or accountability controls.
Not included
- Excludes generic clinical governance, incident investigation or organisational learning failures not specifically concerning coronial autopsy or post-mortem processes.
- Excludes failures to disclose information to coroners or inquest participants where the concern is the inquest disclosure process rather than the conduct or governance of the autopsy.
- Excludes failures in clinical care before death unless they directly concern the coronial autopsy or post-mortem process.
- Excludes forensic or clinical pathology deficiencies with no explicit coronial autopsy or post-mortem process connection.
- Reports
- 6
- Individual concerns
- 9
- Date range
- 2019–2025
- Stated actions
- 6
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised2
Lack of a standard protocol ensuring appropriate samples are taken at the correct time
Failure to collect and store an early post-mortem blood sample for later analysis
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Publish autopsy guidelines for suspected acute anaphylaxis, including blood and stomach-content sampling guidance.
Stated by Royal College of Pathologists
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Published anaphylaxis autopsy guidance and expected use of relevant guidance are considered sufficient despite paediatric guidelines lacking specific anaphylaxis details.
Stated by Royal College of Pathologists
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Position
Femoral blood sampling in very young children may be impractical, requiring alternative sites that complicate interpretation of mast cell tryptase levels.
Stated by Royal College of Pathologists
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Concerns raised1
Failure of the SUDIC Protocol to reflect the development of molecular autopsy
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Raise revision of the Sudden Unexpected Death in Children protocol with the Royal Colleges and relevant government departments.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
RCPath is the appropriate organisation to comment on concerns about molecular autopsy.
Stated by NHS England
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Concerns raised2
Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination
Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
Stated by UK Health Security Agency
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Position
Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.
Stated by Food Standards Agency
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Concerns raised1
Failure to retain the placenta for full paediatric post mortem examination before coronial reporting
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Maintain a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.
Stated by Nottingham University Hospitals NHS Trust -
Action
Review whether placental examination processes need adaptation after receiving further information about the examination.
Stated by Nottingham University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.
Stated by Nottingham University Hospitals NHS Trust
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Concerns raised2
Lack of regular independent peer review of coronial autopsy reports and processes
Failure to produce accurate and satisfactory coronial post-mortem reports
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Cursory post-mortem investigations following assumptions of suicide
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Include guidance advising coroners to consider the need or scope of post-mortem examinations in deaths involving potentially self-inflicted stab or gunshot injuries.
Stated by Office of the Chief Coroner -
Action
Publish new guidance on second post-mortems and post-mortems more generally, including encouragement to consider CT scans and photographic or video evidence capture.
Stated by Office of the Chief Coroner
Data last updated 7 September 2026