Matthew Gayle · Prevention of Future Deaths report

On 14 December 2016 I commenced an investigation into the death of Matthew Gayle aged 31 years. The investigation concluded at the end of the Inquest on 26 March 2018. The conclusion of the inquest was natural causes.

Matthew was a serving prisoner at HMP Oakwood who was found dead in his cell on the morning of 8 December 2016. It has not been possible to determine the precise cause of his death but it is likely to have been naturally occurring.

Histopathology is very important for determining causes of deaths and it can play a significant role in preventing deaths in the future. When Matthew was found dead he had some illicit drug paraphernalia in one of his hands. He was a young man and the immediate suspicion was that this was a drug related death. The pathologist who conducted the autopsy examined Matthew’s body and took samples for toxicology. Toxicology was carefully carried out (including checking for new psychoactive substances) and the result was that there was nothing in Matthew’s system likely to have caused his death. No histology had been carried out because it was anticipated that toxicology would provide answers. Possibly if histology had been carried out it may have produced a more accurate cause of death for Matthew.

I would make it clear that I do not seek to criticise the pathologist in this respect. You will be aware that there are a declining number of consultant histopathologists who are prepared to carry out autopsies for Coroners and many of those who still perform that function are working under substantial pressure. It is important for the proper investigation of death and the prevention of future deaths that there are sufficient histopathologists to carry out autopsies for Coroner when these are required. I would greatly appreciate your assistance with the following:

1. Are active steps being taken to increase the number of consultant histopathologists who will carry out autopsies for Coroners?
2. Will it be a compulsory part of training of doctors who wish to become histopathologists that they do have experience in Coroners’ autopsies?
3. When engaging consultant histopathologists will NHS Trusts appoint doctors who are both competent and willing to carry out autopsies for Coroners?
4. When appointing consultant histopathologists will NHS Trusts ensure that their contractual arrangements enable them to have time to carry out Coroners’ autopsies?
5. Is there any move to increase the fees payable to consultant histopathologists for carrying out Coroners’ autopsies?
6. Are any steps being taken to progress the Hutton report in establishing specialist centres for histopathology?
7. Are you able to provide me with details of any consultant histopathologists who are prepared to carry out autopsies in the large geographical area that I cover?