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Clinical (C) standard

The purpose of the clinical domain is to ensure that a PMC-SI service, wherever it is operated, provides a rapid, safe and accurate autopsy diagnosis while at the same time seeking to maintain and enhance the service. This is achieved through administrative and clinical practices appropriate to the client group; effective communication strategies; and the review of existing and new practice that develops and improves the service.

C1 The service implements and monitors systems for requests, referrals and other relevant information throughout the pathway.
C2 The service implements and monitors systems to ensure the acquisition of optimal diagnostic quality images.
C3 The service implements and monitors systems for appropriate communication of findings.
C4 The service implements and monitors systems to manage clinical records and confidentiality.
C5 The service implements and monitors systems for regular audit including current practice and the development of emerging practice.

C1  The service implements and monitors systems for requests, referrals and other relevant information throughout the pathway

Following a request for a PMC-SI, a Coroner (or, in Scotland, a Procurator Fiscal or Sheriff) must authorise the procedure before the Coroner’s office contacts a pathologist. On the basis of a full history and circumstances of the death, the pathologist will be able to confirm whether PMC-SI is appropriate.  The service should work collaboratively with colleagues to agree and deliver the appropriate imaging within required timescales.

a. Systems in place for appropriate referrals with sufficient relevant information for a scan to be carried out and any relevant post processing of the images undertaken.
b. Systems in place to manage the administration of the client pathway from referral to return to the referral source.
c. Systems in place to support collaboration between the image producers and other clinical staff (namely radiologists and pathologists).

For any authorised PMC-SI examination, the pathologist must retain a central co-ordinating role (RCR 2012). Local systems for referral authorisation and record keeping will need to be developed and pass through the appropriate clinical governance procedures.

C2   The service implements and monitors systems to ensure the acquisition of optimal diagnostic quality images.

Good quality images are paramount. The workforce involved in acquiring the images must have the appropriate level of education and understanding of the modality and forensic imaging including the relevant anatomy. The scanning equipment being used should be considered when developing imaging protocols and due regard applied to the technical capabilities of each individual CT/MRI scanner. As technology evolves, protocols will need to be updated in line with equipment developments and care must be taken that protocols are not inappropriately ‘shared’ between different generations of scanners resulting in poor or inadequate images. The workforce should be able to demonstrate they have sufficient knowledge to appropriately optimise the equipment. Post mortem results are predicated on reliable evidence for a diagnosis to be made.

a. Systems in place to ensure that persons undertaking the role of image producer have the understanding of, and ability to make the best use of, any imaging modality used to produce the images.
b. Systems in place to ensure that consistently  excellent quality images are produced to enable unequivocal findings.
c. Systems in place to ensure that image acquisition protocols are developed and agreed through consultation between image producers, radiologist and pathologists.
d. Systems in place to assure that protocols used for image acquisition are grounded in current best practice and reflect relevant professional guidance and statutory requirements (Imaging Services Accreditation Scheme – ISAS-, 2014).

The appropriate level of education and understanding of the modality and the relevant anatomy demonstrated are required to ensure images are optimised for diagnosis.  Images do not just ‘appear’ due to following a protocol, but require understanding of the nature of imaging.  A radiographer educated at Higher Education Level 6 (Bachelor) is able to undertake imaging at the appropriate level to ensure consistency in the production of suitable high quality images: this includes the basics of CT and MRI image production.  Post registration training in complex Computed Tomography and Magnetic Resonance Imaging enables radiographers to understand and have the ability to modify scan parameters and sequences. In addition they have the fundamental education to be able to perform post processing in a wide range of image modalities.   Postgraduate education in Forensic imaging is essential for radiographers to be able to fulfil the medico-legal requirements of these examinations (SCoR 2014).  The highly trained CT radiographer in association with the Multi Disciplinary Team (MDT) is best placed to ensure that protocols are optimised for the equipment capability and image quality required.

A PMC-SI service needs to assure itself  that the images are of an excellent quality. In CT, however,  it is considered by some that no single protocol is the ‘correct’  protocol as acceptable image quality can be achieved using many different combinations of scan parameters (American Association of Physicists in  Medicine). Local protocols should, however, reflect national guidance (RCR/RCPath, 2012) and be based on best practice evidence. Radiographers have the depth of education to understand image quality issues and develop appropriate protocols for successful imaging outcomes.

C3  The service implements and monitors systems for appropriate communication of findings

All radiographers are, by the very nature of their professional activities, film/image readers as well as image producers.  Radiographers are educated to identify ‘normal’ appearances in the images they produce and thus as a corollary know when ‘abnormal’ appearances are present (Challen 2011).  Further education will be necessary to identify relevant post mortem changes affecting image appearances and to differentiate between pathologies and post mortem artefacts.

a. Systems in place to ensure that the image producers (radiographers)

  • understand the principles of image acquisition and are able to evaluate images,
  • can distinguish between normal and abnormal findings/artefacts,
  • are able to assess the quality of all images produced,
  • understand and implement required actions where additional imaging may be required.

b. Systems in place to ensure that image producers are in a position to provide the relevant clinicians with information on pertinent findings.

The radiographers’ role in reviewing and communicating information on acquired images should be agreed.

C4  Clinical records and confidentiality

Images, acquired data and other records generated in PM-CSI may be used as evidence in court. Ensuring the integrity of the data and the associated processes is essential for the images to be allowed as credible evidence.

a.Systems in place to ensure confidentiality is maintained in accordance with legislation and all relevant standards of professional conduct and ethics. All information relating to the case should be considered and is subjudice  (SCoR Code of professional conduct 2013; HCPC Standards, SCoR Guidance for Radiographers providing forensic radiography services 2014).
b. Systems in place to ensure that all images produced include appropriate identifiers, ID markers, subject ID, radiographer ID, witness ID,
c. Systems in place to ensure that records are kept in line with SCoR Forensics guidelines 2012,
d. Systems in place that evidence the pathologists, lead radiographer and lead radiologist are satisfied that protocols and processes are in place that meet all the necessary medico-legal considerations for records and confidentiality ( SCoR, 2014),
e. Systems in place to ensure that images and raw data are handled in accordance with section 20 of the SCoR Guidance for radiographers providing forensic  radiography services (2014), and systems exist for provision of the images and data to the referrer.

HCPC registered radiographers’ standards of practice require them to accurately annotate images, ensure subject identification occurs to rigorous standards and apply relevant professional or legal standards to their practice.

The issue of image storage or image access for the coroner or procurator fiscal will need to be considered in any agreed imaging protocols and service level agreements.

Postgraduate level education in forensic radiography is essential to provide the radiographer with the required knowledge and skills to image PMC-SI cases in accordance with all statutory and legislative requirements ensuring that, where required, images produced would meet all requirements for admission in court.

C5  Regular Audit including equipment quality assurance, current and emerging practices

All equipment used throughout the PMC-SI process must be fit for purpose, regularly quality assured and correctly maintained. As with any rapidly evolving technology providers of services will need to be aware of best practice in this field and have the ability to test their service provision against best practice parameters. 

a. Systems in place that demonstrate the PMC-SI  service undertakes regular image quality control tests,
b. Systems in place that demonstrate the PMC-SI service undertakes regular audits,
c. Systems in place to ensure that radiographers and support staff have access to relevant  CPD related to current and emerging practices in forensic imaging.

Image audit and the contribution to definitive diagnosis should form part of the clinical governance procedures for the service.

In order to practice, radiographers must be registered with the Health and Care Professions Council (HCPC) which in turn requires demonstration of Continuous Professional Development (CPD) in the area(s) of each individual’s professional activity. This implies keeping up to date with both current and emerging practices in Forensic Imaging.

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