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In the next break, I've just to let you know to go and visit our sponsor revised radiology who are doing a 20% off subscription deal for people who have attended our conference until May the 21st. So we're really happy to announce our first speaker for the afternoon, which is Doctor Clair Robinson. Um She is a consultant radiographer in Leicester, who was involved in forensic and postmortem imaging for over 20 years and an expert in the development of postmortem ct as an alternative to autopsy. So I'm excited to introduce her talk here today on postmortem imaging. Thank you very much. So, thank you. So I have to say I feel a little into local today as the only non radiologist. So please bear with as a radiographer. Um So yes, when you talk a bit about postmortem imaging and what it involves and what, what it is and how we do it a little bit. So I tend to use the phrase postmortem imaging because I only deal with the dead. Um I no longer do any live x rays. And people ask me is that I'm not a bad thing and I say No, my patient's don't moan. My patient don't complain. Um, I have an easy life. Um, but if we think about the word forensic, it actually means pertaining to court's and law and therefore there is a live element in that. So, imaging for suspected physical abuse and our daughters or Children would come under the forensic radiology. Um, remit if you like. Um, but also things like murders and coroners, investigations or coroner's inquests. But a lot of the work that I do, the vast majority of work I do now in Leicester is no longer forensic. Um, it is non suspicious death. The window isn't gonna go anywhere near a coroner's Chorzow. I tend to use postmortem imaging because that's what I do. So we do it because we're asked to, I use the phrase asked by a coroner, uh, loosely because it's kinda one of those questions you don't say no to. Um, so they do generally ask politely. It's all right. Um, and their job is to answer the four questions we've got here. So who the person is that passed away where they passed away when they passed away and how or why they've passed away on that day at that time. Um, and this is what happens in England and Wales, the laws are slightly different in Scotland and Northern Ireland and after the elsewhere in the world are very different. So this is what we do in Leicester because we're working under the legal jurisdiction of England. So, obviously, on CT scanning, we are quite good at who, which I'll come onto a little while. Uh, because the majority of people that get referred to us, at least we know exactly who they are when they referred to us. Um, so we don't have to worry about that too much. Um, where and when I, we don't touch it with a barge pole, basically, uh, people, pathologists and on the telly, they'll say, oh, this person died 3.5 hours ago. Uh Which pathologists when you talk to them, we'll just say that doesn't really happen. Uh Obviously, if someone has died in an R T C, there's so much CCTV around now, it's far better to do it off, something like that, an appropriate source. So we don't get involved in where and went on imaging, but we do get away, get, get involved in the how or why someone's passed away. The only exception to this for imaging for the coroner is when a patient doesn't, when the pirate ship passes away and doesn't have to be referred to the coroner. So they're a small number of cases where medical certificate of cause of death will be issued or legally, the patient doesn't have to be referred. So things like uh deceased like stillbirths, um don't have to refer to the coroner in some circumstance. So we may be that the family will then want an investigation. So those used to be traditionally called hospital postmortems and are something that a bit of a dying breed. Uh People don't tend to ask for them anymore, but now we started doing them by CT, we are finding that more families are asking for them um for adults. Um And for the pediatrics. Um As I'll explain in a moment, we still do those with plain film. So who do we include in our postmortem imaging? Well, any age um and anyone who's passed away really in any circumstance. Um So as I mentioned, stillbirths and medical terminations um right through to unexpected death in Children, most child deaths have to report to the coroner. Um nonsuspicious deaths will report to the coroner. And these are people referred to the coroner who haven't been given a medical certificate of cause of death, which means we're dealing with a limited number of pathologies if you like, which I'll come onto in a moment, we deal with forensic cases in Leicester. Um So suspicious deaths, murders, homicides, things, whatever you want to call it. Uh And we also do some mass fatality work, which I'll explain in a moment. So training on the age of the person that's passed away two term is what sort of imaging we use. Uh We are a little bit controversial that not everybody likes baby grams. Um But we do it in a very set, a very strict protocol of the child has not left hospital. It has been a medical terminations or still birth. And that's the only time we use it. Um And it's because of the volume, partly because of the, we have an awful lot of cases and it provides sufficient information um for the pathologists that we work with, they're happy with that. If more information is wanted in a complicated death, then we will consider MRI for some foetuses as well. Um So like we had a pediatric imaging for suspected physical abuse is sit down in the RCR guidelines. Um And we do the same imaging for the deceased as we would for a live S P A investigation. So the full skeletal survey that under 2.5 years of age, if it's a suspicious death. So any suspicion that trauma has been inflicted on a child and it's referred by the forensic unit, then we will do a skeletal survey and a CT scan as well under 2.5 years old. And there are some circumstances that are really important that we do do the CT if they're considering oration of the lung. So you can see on the image on the side here. Uh There's something here but you can see here that the lungs are, are filled with um for the show, sorry, fish on here. So the aeration of the lung and there's something including here. Um and this is something, this is a child that was passed away. Um It was a concealed pregnancy. So the mother didn't disclose they're pregnant, gave birth in secrecy. Um And sadly, the child passed away, but obviously had taken its first breath. So, excuse me, a child over 2.5 4 and our dog gets plain, plain ct scan and I'll talk to you about the protocols. So, are we doing this instead of an autopsy or are we doing this as well as an autopsy? Um And it does rather depend on the age that we're looking at. There's been a lot of research done by a celestial other groups about using imaging instead of um autopsy, invasive autopsy. Um but the pediatrics, the research isn't there. And I think it's part of the reason that is because there's so many variables in pediatric death, there's congenital things and there's all sorts of genetic things that need to be considered. Um And they're doing, they are doing a lot of work research in Great Ormond Street and several pediatric centers around the world. But that research isn't there yet. So for pediatrics, it's definitely as well as an invasive autopsy and it will depend on what imaging you're using. I'm talking about CT here, but I know there's a lot of hospitals around the country who are still using plain film and um philosophy for these surveys. So in which case, you're not gonna be able to do as an alternative to. But when we can produce imaging like this, um for a forensic case, there's no doubt why this person's passed away. They will still have an autopsy. Um It's the law in the, in the UK. Um And that's what happens. So generally speaking with very few expected expectation exceptions now, sorry. Um, they will still have an invasive autopsy, but as we all know, CT is fantastic at trauma. Um And so we started out our research 20 odd years ago, um looking at trauma cases and could we replace CT, um could CT replace autopsy? And very quickly realized that having done a CT and autopsy control study, that CT was better at looking at trauma unsurprisingly because we all know that we're very good at it. Um The pathologies weren't necessarily very happy when we pointed out that missed fractures, missed one quite big fractures. Um But things like association of the C spine isn't uncommon to us. Um Open book fractures, things that you'll see read about in theory, but not necessarily seeing practice very often if you want to see them come and work with us, come and do some post mortem imaging because you will start to see some of the more unusual fractures and as well when we're dealing with the non suspicious deaths. So perhaps somebody who's been found passed away in bed at home in a locked house where there's no, nothing has potentially happen to them. Um We're quite good at these 85 90% of the patients get, get referred to the uh hospital at Leicester for an autopsy or post water examination and have a CT scan. Um Don't go on to have an invasive autopsy. Now, a lot of those that do, we'll just have a toxicology sample maybe. So, how do we do it? Uh Simple protocol used to be in the RCR postmortem region guidelines when some reason they took it out, I don't know why, but if you want a copy, let me know what I can find you one with one. Um But it's, we do a head and neck block. Um so vertex down to about T two T three, then we do above, above shoulders, chest, abdomen, pelvis, down to synthesis pubis or below the fingers depending on which one is lower. Uh We scanned legs, we also do an angled head and neck block which I'll just come onto a moment. If we're scanning for trauma or forensics, we will always include all soft tissue and feet and arms. Um But if you imagine we're doing a patient for nonsuspicious death has been found passed away in bed, they're gonna have died from something that happened in the head or chest or abdomen pelvis. And therefore, if we got a limited field of you in a larger, you're scanning a larger patient, it can be quite difficult to get the arms in the field of view, you can cross the arms over which helps an awful lot. And reduces beam hardening artifact as well. Uh It doesn't always work but if we were doing an on suspicious death and we weren't worried about anything in the arms. If you can't get in the field of you and you just abdomen pelvis don't go too, too much effort. If they died of trauma, we go to a lot of effort. And if need be, we roll the patient on to it's side so you can pin the arm onto the bed, um and scan it, get it in the field of you that way. So angled head and neck, we are a bit weird in Leicester that we do this. Not many places in the country around or around um internationally do this, but we were finding were potentially missing c spine fractures and problems in the posterior fossa of the brain because a lot of our patient's come to us dressed or we'll have hearing aids in or we'll have dental restoration which causes obviously artifact on CT scans. So by angling the brain and doing the whole angling the tube, sorry and doing a whole head and neck scan again, throws off a lot of the artifact and gives us more confidence that if we are dealing with trauma, patient's and particularly motorcycle accidents, um We don't miss the c spine fractures that we're looking for problems. I am a little bit mean with my reconstructions. Um But when we started doing this are packs manager got very, very twitchy because we're putting 4.5 to 5.5 1000 images on packs for each patient that we scan. Um And so we just, that's just with a bone and soft tissue with the reconstruction for the whole body and brain window for the angled head and neck. Um And that's just because of the number of images do we do at 1.8 reconstructions for the head, chest, abdomen, pelvis, two and 1.8 for the legs. We don't need quite so much detail, but it wouldn't matter whatever Corona Law, Sagittal reconstruction we did. Our patient's don't lie straight and therefore, doesn't matter what we'll give you, it would never quite work. And when we're looking at things like this, um it doesn't matter what we gave you, you'd have to do reconstruction specifically to see something like this. And therefore we don't worry too much. And as well, now everybody's got workstations in the, in their offices or at home for some radiologists and we've done the same with our pathologists. They've got all workstations in their office is um so they can do their own reconstructions now. So for our trauma, patient's are forensic patient's, our pediatrics and a lot of our nonsuspicious work, this is where we finish. That's enough. We don't need to do anything else on our patient's and that will give us the cause of hopefully give us the cause of death on most of them if we only one in a position to do that. But for quite a lot of people, that's not enough. So, and it's because the, the population that are referred to us. So those that haven't had a medical certificate cause of death. So we're not looking at cancers, we're not looking for stroke, we're not looking for various other things that people will be given a medical certificate cause of death for because they have been seen in a hospital or a GP be willing to issue. So this population of people who've died unexpectedly and suddenly. So in, in our world, ischemic heart disease is one of the biggest, the biggest kid. It's the most frequent thing you'll see on a medical certificate or radiology report if you like. Uh and therefore we decided that we wanted to look at the coronary arteries in more detail. And therefore we developed a technique of doing coronary angiography in the deceased bit weird. Yes, we agree. Um But we, and as well, we're looking at other, what other places were doing around the world. And there's a fantastic group in Switzerland or two groups in Switzerland who do some amazing whole body angiography techniques. Um They inject 3.5 liters of fluid contrast diluted in paraffin oil. Um And the picture's beautiful, but the equipment is tens of thousands of euros. Um We don't get paid that for uh personal to imaging, unfortunately. Um So we went down the line of using stuff that we've got in our radiology department, um, and, uh, using our CT pumps, everything that we've got normally. So how do we get the catheter in? So we make a small decision above the left clavicle. We, uh, find the carotid artery isolated, lift it. We'll put a foley catheter in. If you're gonna try this, make sure it's a male foley catheter cause it's longer and make sure it's got a 30 mil balloon on because the standard Foley catheter has a 10 mil balloon. And what you want to do is you put the, put it down, hopefully goes down the clotted down into the ascending aorta, you then inflate the balloon above the coronary ostia. So, so occlude the ascending aorta and then you can put contrast down it, training radiographers, right? And they'll know how to move the balloon and that's what we do. So the radio was have to interpret the position of the balloon. Um It's technique that works fairly well. We're going through a run of, not so well at the moment but why we don't know. But that's one of the things we're analyzing now to see what, what's the problem is. Um So at the moment I'm trying to do this, I can do it if I want, if I need to, I'll try to avoid it. I must, doesn't it? But um, or two technicians do this for us before they leave the scan, the mortuary to come to the scan, er, it only takes about 5, 10 minutes is not, not a complicated thing. And then we used two types of contrast. So we use clinical contrast dilute, clinical contrast diluted in water 5 to 10% depending on what sort of contrast you're using, what that, what strength it is. Uh And we do this because we want to look for soft common road plaque and we want to look for calcified plaques. Uh And we find that the soft plaques show up whether it be a nice partial occlusion or whether it be complete occlusion. Um And we need the fluid to do this. Obviously, our population because of the nature of the population that's referred to us, they're all mature, largely the majority of a mature population. So, over 65 therefore, they generally have calcification. And what we were finding was to diagnose stenosis uh when the classified stenosis, particularly when they're like, but when they're pinpoint stenosis is difficult using positive contrast. Um And therefore we decided to use air. Um and it works beautifully and if you're, if you're ready to say well, no, no, my my my pump inject will say is all the air out and I have to say no, I have to say yes, it is. If you just go yes, it is. And then inject air, some pump injectors will just do that. Um And so you have to pick your pump inject a little bit carefully, but it does work. Um And so we do a series of runs, we do five runs in total three with fluid contrast and two were there. Um And you'll notice that we've turned the body into the right to cubitus position um in that image. And the reason for that is sometimes get something that is called post mortem clot. This is not a pathology, this is something a pathology uh artifact. Um And it's because of the blood cells are coagulating plasma is disappearing. So you get this appearance and it's like um pathologies call it red current jelly. And that's what it looks like. If you're seeing, it is very gelatinous and it quite often sits in the ascending aorta. And you can see here it's completely including the left main stem. Um And this isn't unusual and therefore we roll to get rid of the clot, any clot that's present. Um And you can see it's actually sediment ing out on the, on the, on the left where we've rolled it. But as well, we found that sometimes because the ask the right coronary artery is uppermost when they're supine. If you put fluid down, you sometimes get a little air bubble sitting over it. So you never fill the right coronary. But by rolling to the right coupet's position, the RCA is now heading downhill. Uh And we can encourage shift to fill with fluid that way. So the last run that we do, so we do two Supine with fluid turned with uh fluid contrast, then we do an air contrast with them turned and then we do uh the last run with their uh supine again, it enables us to take advantage of getting rid of the clock and gravity with the contrast. But we were looking at around GEOS and we aren't they lovely. Yes, but they do take 45 minutes, 40 minutes to do. Um And we would say we were looking at the coronary artery calcification realized that a lot of our patient's have Abbottston scores of 45, 6000. Um And therefore, was the actually the angiography actually necessary. Um So one of my phd chapters, we're looking at looking at this um and when you can see that you could see you could trace the coronary artery right the way down its length is really angiography necessary. Um One of the studies was looking at the Agatston score ing of these patient's. Um And we came up with a score of 400 that was appropriate. Should we say we could have dropped sensitivity and specificity wise, we could have dropped it to about 201 197 and I guess we saw 100 97. Um but morally, I didn't feel quite right because clinically a score of 400 is severe. So if we're saying you could diet with a score Gleason score of 200. It didn't sit quite right. Um So we've set settled with 400. Um And that's our cut off anybody with an Agusan score of 400 doesn't go on to have angiography. It doesn't need to go on to have an angiography now. So we've added a contractor, classification scan, scan um into our protocol now as well. Um But sometimes it is nice to do angiography because we get nice things like hemopericardium quite a lot. Um And we know from the pattern, um you'll see you've got these fluid levels and that suggests that this wasn't uh particularly necessarily sudden you get to two patterns of hemopericardium. Um And this one as it turns out it was due to aortic dissection. And you can see that by doing the angiography and put in the contrast down the flap shows beautifully shows beautifully there as well. And if you see a dissection, flat radio officer trained to scan the abdomen afterwards, the chest and abdomen because you see that it shows you then at the extent of your dissection flap um which is something nice to do. And of course, hemopericardium can also be ruptured in my. Um And it's really nice that we do angiography in these cases so that we can actually see the rupture sites. And then of course, that's the cause of death, given problem solve, we're not going to do anything else. So that's how, what we do for a vast majority of our nonsuspicious deaths. But I mentioned massive Haliti work and it's something that we do in Leicester and I'm involved in nationally. Um It's a process that's internationally agreed. I'm just going to briefly cover this called disaster victim identification. It's Interpol led, it's uh say internationally approved and it's a whole process, paperwork and radiology in the last four or five years has become absolutely crucial. And in the UK, we now will no longer do a D V I exercise or event sorry, without doing a CT scan at the beginning. Um So we're becoming quite important in this. Um This is a photograph you'll see from the N H M team um investigation over in Holland um where the deceased was scanned there. I'd say this is an internet image. Um So it is really available information because the scans are different. Um And you can imagine trying to interpret something like that's going to take a while. Um And we have to be aware that this sort of work, it becomes a little bit taxing for everybody involved because it's as taxing for somebody reporting the imaging as it is for us doing the scanning. But it's nice when we can start to look at how we can use that imaging differently. So this is, the paper has been published by my colleague Mike Biggs and Fill Marston um where an incident happened and the teeth weren't readily available to three Odontologist Dr Marsden to review. So, pathologist Mike took the scan with the CT scan, the CT scan within a couple of hours of it being done. He three D printed the the teeth. Uh the odontologist was able to use that some dental x rays that were produced from the CT scan as well. Um And some photographs he found online to be able to identify the individual without having to disrupt the person more so huge step forward and um something that is hugely beneficial to the families as you can imagine. So obviously, as we're here talking, talking to you guys, I thought include a little bit about reporting in these cases. Um because obviously that's what you'll get involved in potentially. Um And it is different, it's very, in fact, it's quite different to clinical. Um And for some people, this is quite a step change because the clinically you've got to be 9900% certain of what you're giving or what you're saying is a diagnosis where as we work for the nonsuspicious work on a balance of probability. And that's the legal law statement in the UK or England and Wales, sorry, England and Wales Scotland is slightly different. Um And so balance of probability can mean 60 40 or it could be 90 10%. Depends on the circumstance, depends on the coroner, depends on the pathologist, but it's a very different concept that the radiologist no longer has to be absolutely certain on what they're suggesting might be the cause of death. And it, it's quite a step change from your clinical diagnosis if you're involved in forensic work. Of course, that is beyond reasonable doubt. Um And there is a, so there is a difference and I think being aware of the legislation that you're working in and the remit your reporting in is vitally important for us all and knowing what we can and can't say. Um So I think for, for us looking at the imaging um us uh joint, uh we need to know what's normal for dead. Uh because there are certain things that happen like the postmortem plot that is normal and shouldn't be MS mixed up with the pathology because that's when we start to get into trouble. Uh And I'm selfless, shameless plug. If anybody's interested in learning more, we do courses in Leicester. Um We're doing courses for, just to let you know as well. We've been asked by the RCR to think about doing a national training for um registrars as well because it's in your syllabus now. So that is on the cards um as well as a three day course for radiologist, which registrars are very welcome to join. So I can't not say that, can I? So some of the things that we see that commonly different, obviously, we deal with the composition that you wouldn't expect to see uh in the clinical scan. It does look different. It's sometimes fairly obvious, it's sometimes really not so obvious. Um But studies done in Switzerland and Silky Grabbers Group in Luzon have looked at the order in which the decomposition gases are seen. So the place to start, if you're going to start looking at these scans and you think you might have decomposition gas, look at the liver and that's where it first appears. Um So if you see a neuro peritoneum, for example, and there's no gas in the liver, then it is a neuro peritoneum and the cause of death potentially think. Um But if the gas in the liver, then you have to ignore the pneumoperitoneum or, or take it, you know, deal with it carefully, shall I say? Um So decomposition can also be a little bit misleading because you get intravascular air. Um And so the image on the like if we saw that clinically lead, you might think it was a traumatic um stellate fracture of the lumbar spine. But in fact, for us, that's just normal gas in the, in the vascular structures of the bone. So, but it's very easy. You can imagine that if you don't, if you're not looking for these things and you don't know it and it was an R T C and somebody passed away as a as a result of trauma, you could mistake something. And there's a lot of papers if you go back about 20 years ish that we're reporting these as, as, as a trauma. When in fact, a few years later, people realized that it wasn't, it was what we call, you know, normal a postmortem ct scan. And also if we saw some of the neuro images we saw earlier aren't dissimilar. Um but we deal with settling of blood products because obviously the once that we'll know that once, if blood is put in a test tube, it settles out. And the same thing happens in the deceased once the, once the heart stops. So we have to deal with looking at what is normal artifact for deceased. And the hematocrit effect is just the blood that's settling out and this is normal for for deceased brain scan. Um So straight away, we know just ignore that, but equally, we can't ignore it completely because is this hemorrhage or is it artifact? So if we look at the c spine actual, the patient have a lot of spinal fractures. But the so that some of the, some of the artifact and through pathologies are quite subtle and therefore we do have to be a bit careful and as well, some things that appear to be trauma aren't. So you can see there's a cease by fracture here. Um But when this was reviewed, um on the scan, there's actually no blood around it at all and there are things called mortuary or handling fractures. Um And you sometimes see them after CPR as well and they're, they're just fractures that happen because the deceased, um the bones are so fragile. Uh It's not that the mortar being heavy handed or being difficult with. These are things that are recognizing the pathology world as just one of those things that happen and normal. Uh And you may see t spine fractures when somebody's had a lot of CPR as well. And again, it's something that is not unusual for a P M CT scan. So it's something that we need to bear in mind. And of course, when we're looking at the common re arteries, we have to think about has a little bit of the clot gone into the coronary artery or is it true occlusion? Um The imaging on this side um is post water clot. Uh You can see there's a meniscus on either side of those two little bits that I've highlighted in here. Um Whereas true occlusions don't have that meniscus appearance. Uh it may just be closed down completely or it may be partially closed. But you can see the cross section here enough to give us cause of death fortunately, but things are not always what they seem. And sometimes we see things and people, radiographers can get very excited because our radiographers do give us suggestions what they think because we think how good we can get our trainer, Ray doctors to be. And I have to say this is one occasion where radiographers will not be able to report in England at the moment anyway, because the law says it's got to be medically qualified person that gives cause of death. Therefore, we can't get involved, unfortunately, but we'll see how we go. Well, I'm pushing forward a little bit. Um, but if it does mean that the way we do ask the radio office to have a look at the scans and see what they can see, um, and sometimes they, they will see, they'll pick up things and say yes, tablets potentially. Um And we then we have to make sure that that fits with the history of uh was their medication found where near by the deceased or because it could be something else and sometimes things are slightly more subtle as you can see in the stomach. Um But in fact, that was just their tea and that was pasta. Um So we just have to bear in mind that sometimes you can get very excited and think, oh, we found something really, really interesting and in fact, it's just their t um so just it's, you have to be careful that things aren't always seen what we expect, what we um uh you don't see what we expect and the scans are definitely not clinically normal. Um You can see this patient has suffered um extensive facial trauma, um scan the other fractures through the skull as well. Um But the, but I'm interested in, is this any ideas? No? Okay, understandably. Um this is a bit of a weird, well, this, this foxed, some of our radiologists on that course as well. Um And what we, what I, what I should have said was this patient had been repatriated and when you repatriated, you have to have, you have to be embalmed before you can be repatriated. Um So this patient had suffered trauma in another country, had been embalmed and then return to week scan when they, when they come back. So, in fact, this is packing that is normal that we see postmortem in after, after embalming processes. So nothing unusual, nothing to worry about. Although it does mimic maybe an abscess or something like that are very absent, you know. So again, it's about knowing the circumstance under which you're, you're scanning and the circumstances that led to the patient's passing away um as well, you know, to make it fit with the history and as well, we'll find that if they've been embalmed, there will be injuries elsewhere that you might think are huge horrendous trauma injuries. But in fact, just the process of embalming that is done because different countries use different processes to embalm. So it's really important that you know, the history and you put the history with this scan to make them match up because otherwise you can end up coming to drawing the conclusion that is really not very accurate at all. And we have to expect the unexpected. Some people we get passed away at home, no suspicious circumstance. And then you start to look at the scandal thing. That's not that this doesn't match. Um, so we had one lady who had, had a huge fall, um, and had actually broken her arm. No, it wasn't reported anywhere. But of course, that then they introduce an element of trauma which then needs to be discussed with the coroner and the, you know, the pathologist does that make that, that discussion? But it's then determining whether that there needs to be investigated a suspicious death because that doesn't hit. The story doesn't match the injury doesn't happen very often. But it's important that that's, that is that you're aware of this. So this was the history on this gentleman. Um And if we look here, oh, sorry me point is kind a bit wonky. Um We've got a foreign body there and it was actually had swallowed his dentures. Um And this gentleman was seen choking, but they didn't realize what the matter was. Um And sadly, it was put down that he passed away because he choked on his denture. Unfortunately. So, so hopefully that's shown you a little bit about postmortem ridging and how it's done and how it can be done. Um It is different. It's not for everybody. Uh We have certain radiographers and certain radiologists who really don't like it being done and we make sure that they're not included at all. Uh But if it is something that you're interested in. Uh let's say if your, let us know unless the contact us, if you want to come and see us and see what we do, it is starting to be done more in more places around the country. Um So there are more opportunities for it. Um And if anybody wants any help setting up services, I'm more than happy to do that. I'm helping several centers at the moment but you just to, just to go back to two, I think really important points if you getting involved in this, make sure you know what you're doing and make sure you're working within the local legislation because this was a headline that came out not long after the MH 17 investigation. And I don't want to be put in that position where I'm losing my job. So it's very much about knowing what you're doing, what you can and can't say and, and working within the legislation to your country and making sure that you're doing what the coroner expects of you and that you're not overstepping that mark and all. So the procurator fiscal in Scotland, for example, having that working relationship so that everybody knows what they're doing and everybody's doing the right thing and the proper thing. Um, and the other thing that I think is the part of the most important thing is if you get involved in this work, whether it's one patient or whether it's a number of patient's then remember why you're doing it. And at the end of the day, all postmortem imaging is done to help the family help the next skin of, of the person who's passed away. So we can try and help and find out why they've passed away. And hopefully for some people that will mean they won't have to have an invasive autopsy because for a lot of people that is a huge relief finding out that that hasn't been, had to happen. Um This is a picture outside the army base at Hilversum where the Mh 17 investigation happened. And again, internet images, I'm not showing anything that's not readily available. Um But I think it just shows that's why it's important and that's why people would get involved in this need to remember that the family are the most important people in all of this. So, thank you very much. Um Any questions of our border war? Thank you so much, Doctor Robinson for that fascinating talk and I understand you, your schedule. You don't have very much opportunity to answer many questions, but we've got a few minutes. Okay. Um So does anybody have any? Oh, I just first, I wanted to say that if you do set up courses for registrars, please let us know, be great to share with our members. I couldn't be really interesting and valuable to us. So thanks for even thinking about, I appreciate that. I was wondering with pediatric post. Uh imaging, uh, do like a medieval complications hinder or slow down the process of getting involved in the pediatric place bottom imaging or is it actually helping families get answers faster? Yeah, I think speed is an interesting thing because it depends on what you're able to provide locally and what delays maybe in your system already and whether that's the mortuary system or when the coroner system, um, but the pediatric ones, we try and get them done off as quickly as we can. Um But it'll get, it'll depend on the availability of your X ray equipment and your CT equipment locally and then your availability of your radiologists to be able to report them. So I'd say the legality isn't necessarily a stumbling block. Um, but there can be stumbling blocks that you need to overcome within your department to make it as, as an efficient services as you can any more questions? The contrast. But so is it just the heart that you're scanning when you've injected the contrast and then if necessary you out there? Yes. So if, if for our, we just to look at the calories because that's the bulk of the people that we need to rule out cause of death on, um, quite often, we'll see something on the other scans and the radio officer bring the radiologist to say we've seen a brain bleed. We don't need to do anything else. Um And if the radiologist is available, then that's what we'll stop there sort of thing. Um So yes, we just do a scan of the heart. Um But if we see a dissection flat, then we would go on to scan the body afterwards. So we can see the extent of the dissection flat. Just a very quick question on that. Um Following on from that, uh what's the commonest cause of death for the top three that you're seeing after most of the CT and not suspicious in the nonsuspicious cardiac. So I skipped heart disease, common artery atheroma. Am I something around those bronchopneumonia as we get quite a lot of those? Um and then trauma for, for our two for RT season people with no, those are pretty aunts main. Yeah, because you mentioned that when the last headline you were showing from the cardio being aware of those, you know, what may follow from doing this sort of work. Pathologists are very used to going on in front of, you know, it's been a while, for example, giving their opinion and radiologists probably less. So, uh is that something that you also have to drain in? If you want to always instill the pathologist who takes that, it will depend on how you manage your service. So for example, in Leicester, the radiologist wanted to do their reporting in working hours as part of their normal job NHS job. So they've been giving half pas at the moment and therefore, the report is written to give to the pathologist who then gives the cause of death. So anybody goes to the court's, it is the pathologist in Leicester in Preston. For example, there are, I don't think any pathologist involved in their service full time at the moment. Um And therefore the coroner will request imaging, the radiologist, then reports straight back to the coroner. So I know of a radiologist in Preston who has been called to court. And yes, it's, I think as well for radiologist, it's a very different experience because as a clinical radiologist, if you're called to court's something has gone horribly wrong with a patient of yours. Um this is a very different experience. So I think if you work, if you're getting involved in this, get to know your coroner, um it becomes a very different experience cause the radiologist at Preston said it was quite pleasant. Um It wasn't stressful as, as he has. He expected it maybe okay. Any more questions. Okay. Thank you very much. If anybody's got any further questions for Dr Robinson, this is her email address and we'll also circulate it privately between the delegates in case anyone has any further questions. Thank you so much for coming. Thank you. Thank you.