Recommendation 12: Review and update medical records

The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death and death certificate; – name and address of next of kin; – whether Coroner’s or hospital post mortem examination; – date of consent for hospital post mortem examination; – names of pathologist and those in attendance; – post mortem examination reference number; – date of examination; – date of preliminary/final post mortem reports; – date histology completed; – record of specific instructions from the Coroner or clinicians; – record of retained organs, samples, wax blocks, slides, photographs, X-rays, date and method of dispersal or disposal; – case notes; – signed consent form; – copy of any other relevant correspondence or notes; – name and address of general practitioner; – date post mortem report sent to general practitioner; – record of communication of findings to the next of kin.