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Interim Report: Removal and retention of human material

Annex A: An account of the evidence to the Inquiry on the removal and retention of human material at post-mortem


Summary of evidence

  1. The Inquiry received evidence, both orally and in writing, as to the national context in which both Coroners' post-mortems and hospital post-mortems were conducted throughout the period of the Inquiry's Terms of Reference, as to the particular practice in Bristol and as to the events in Bristol once widespread retention came to public attention. Evidence was taken, in particular, from parents, clinicians, the Coroners Society, the Coroner for Avon, the Home Office, the Royal Colleges of Pathologists and of Physicians and from other relevant United Bristol Healthcare Trust ('UBHT') employees.
  2. In Bristol, between 1984 and 1995, 265 post-mortems were carried out on children who died following paediatric cardiac surgery.
  3. Throughout the period, of the post-mortems conducted, 220 were Coroners' post-mortems carried out at the direction of HM Coroner in order to establish the cause of death and subject to the Coroners Rules [1] ('Coroners' post-mortems'); another 45 were hospital post-mortems carried out with the consent of parents, pursuant to the Human Tissue Act 1961, section 2(2), ('hospital post-mortems'). Human material removed at hospital post-mortem may also have been used for medical education and research, section 1.
  4. It was common practice, in Bristol and elsewhere, for human material removed during a post-mortem to be retained for long periods of time by pathologists. In a large number of cases, parents appear to have been unaware of this practice.
  5. Once the extent of the retention of human material was made public, many parents of the children who had been the subject of the post-mortems were very distressed.


1 See Annex B [Return to text]



Published by the Bristol Royal Infirmary Inquiry, July 2001
Crown Copyright 2001