- More care should be given to the formulation of the cause of death for presentation to the coroner and transfer into the medical certificate of cause of death.
- On this group of patients, consented autopsies should be sought more often to evaluate complex clinical pathology.
- In coronial autopsies on ICU patients, increased histopathological sampling should be undertaken to improve disease identification, with the consent of relatives, once the coroner’s requirement is satisfied.
- Pathologists should become more involved in the mortality meetings on ICU patients.
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