Perioperative deaths: a comparative study of coroner's autopsies between the periods of 1989-1991 and 1992-1994.

An earlier retrospective, clinicopathological review of 132 perioperative Coroner's autopsies (excluding cases of preoperative major trauma), conducted by the Department of Forensic Medicine during the period from January 1989 to December 1991, showed that such cases accounted for an average of 2% of all Coroner's autopsies performed during that time. Of these, 15.2% were iatrogenic deaths which were unrelated to anaesthetic complications. Over the subsequent 3-year period (January 1992 to December 1994), there were 170 similar cases, arising from a total of 6468 Coroner's autopsies, representing a composite necropsy incidence of 2.6% (annual incidence: 2.5% to 2.8%) and an absolute increase of 38 cases over the previous period (P < 0.05). Also, the proportion of non-anaesthetic, iatrogenic deaths almost doubled to 28.8% (P < 0.02). Although these observations do not, considered alone, denote a rise in perioperative mortality during the second period (1992 to 1994), as compared to the first, since both studies were limited to deaths reported to the Coroner, they do seem to emphasize the need for a comprehensive ongoing clinical and medico-legal audit of perioperative deaths locally. At present, the proportion of perioperative deaths which are not reported to the Coroner and, thereby, escape medico-legal review, remains undertermined. In addition, as at the end of June 1995, only 23 of 51 pathologically unnatural deaths received a Coroner's verdict of misadventure, with an additional 11 such cases pending inquiry. This rather wide divergence between medical opinion and legal judgement could be a subject of further research.