Despite modern diagnostics, the discordance between ante- and post- mortem diagnoses is still around 25%, reiterating the need for high post-mortem rates. In our study, 3.5% had class I errors that, had they been detected during life, would or might have affected short-term outcome. Another 14% had major errors, conditions recorded as primary cause of death that were clinically missed or unrecorded but would not have affected the outcome. There has been an unexplained decline in hospital post mortems and more than a third of UK autopsies are now performed under the instruction of the relevant Coroner’s office. The UK Coroners’ system is currently under judicial and administrative review to improve the speed of and reduce the need for post-mortem analysis.
