UK Inquiry Tracker

Matthew Gayle

PFD Report Historic (No Identified Response) Ref: 2018-0092

Date of Report 27 March 2018

Coroner Andrew Haigh

Coroner Area Staffordshire (South)

Response Deadline est. 11 August 2018

Alcohol, drug and medication related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, as exemplified by a missed histology opportunity.

View full coroner's concerns

The MATTER OF CONCERN is as follows_ 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 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: Hon: drug would make it clear that 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: would greatly appreciate your assistance with the following:
1. Are active steps being taken to increase the number of consultant histopathologists who will out autopsies for Coroners?
2. Will it be a compulsory part of training of doctors who wish to become histopathologists that do have experience in Coroners' autopsies? 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 cover?

Sent To

Department of Health and Social Care

Response Status

Linked responses 0 of 1

56-Day Deadline 11 Aug 2018

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 14 December 2016 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:

Circumstances of the Death

Matthew was as 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:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action