One in five post-mortem reports register the wrong cause of death, expert are warning as they declare that Britain’s coroners’ courts are “broken”.

A lack of oversight of the work of pathologists means that unscrupulous or incompetent doctors are acting with impunity and denying families the truth of what happened to their loved ones.

It was warned that alongside the damage to grieving relatives, registering incorrect causes of death could prevent insurance pay-outs, shut down inquests and safeguarding inquiries and even scupper police investigations.

With no proper investigation into these deaths, often of the elderly, another Harold Shipman could even fall through the net, it was warned.

The failings have emerged as a Telegraph investigation found that a discredited pathologist, Dr Michael Heath, has been allowed to continue practising despite repeated warnings of failings in his work over the last two decades.

Now, at least four families have complained to the regulator. They are calling for a review of all of his cases amid warnings that he could have got hundreds of causes of deaths wrong.  

In some of the cases before the GMC, Dr Heath recorded healthy organs that did not even exist in the body.

Some of the families will never know the true cause of death as they held a funeral whilst waiting months for Dr Heath’s report to come through.

The families of Alistair House and Amy Dickson, who have come forward since The Telegraph revealed that Dr Heath was still working earlier this year, both thought that they had cremated the wrong body when they read Dr Heath’s report into their parent’s death.

Mr House warned: “These doctors are getting paid from the public purse, and no one’s monitoring the work that they’re delivering.

“There needs to be some sort of review of Heath’s cases because I strongly believe that there is the potential for injustice.”

Amy Dickson's father Stephen Goodenough's post-mortem report said that alcohol withdrawal symptoms had contributed to his death

Dr Heath first hit the headlines after catastrophic failings in his examination of Stuart Lubbock, who was found dead in Michael Barrymore’s pool in 2001.

The controversy over that autopsy, which has been blamed for delaying the police investigation and letting Mr Lubbock’s murderer walk free, led to Dr Heath resigning from Home Office pathology in 2006 just before a tribunal found against him.

But despite a 20-year litany of failings on his record, including two quashed murder convictions, the GMC allowed him to continue carrying out work for coroners’ across the country.

It has been estimated that he could have carried out thousands of post-mortems in this time, and made potentially hundreds of errors of causes of death.

At least four families – including Mrs Dickson and Mr House – have now complained about his actions to the regulator, and strict conditions were eventually placed on his ability to practice as an investigation was carried out.

It is understood that in at least one case a police investigation was halted because of Dr Heath’s conclusions.  

In the report on Mr House’s mother, Ann, Dr Heath described a gallbladder that did not exist, missed the scars of major surgery, and claimed that at just seven and a half stone she was "well nourished".

Mr House hopes that by telling his story more families with concerns will come forward to the GMC and ensure he is struck off for good.

Questions asked as to why he was allowed to practise

Questions have been asked as to why he was allowed to practise after his fall from grace over his criminal work more than 15 years ago.

One former coroner said: “It might be that we are only looking at the tip of the iceberg here. If it is established that for some time there have been serious question marks over Dr Heath’s approach then we could potentially have to revisit hundreds of inquests. It would be a very, very serious situation.

“The families involved are looking for some acknowledgment and an explanation as to how Dr Heath was even allowed to be in the position that he was in. They just want to make sure that other families don’t suffer in the same way that they have.”

The GMC has refused to reveal under Freedom of Information laws how many complaints have been made against Dr Heath, and even the outcome of a public tribunal hearing against him in 2010, citing GDPR rules.

This has led families to question whether they are attempting to cover their own failings. When these allegations were put to the GMC, a spokesman said they could not comment on individual cases.

Senior pathologists told The Telegraph that in many reports that have been reviewed, Dr Heath’s findings “bear no resemblance” to the body, and coroners have been repeatedly warned that he is “hopelessly incompetent”.

As a consultant pathologist he worked across the country, largely in London and the south east, but many officials stopped using his services because of concerns.

It is understood that Waltham Forest’s coroner was among those who struck him off their list because he failed to fill in numerous death reports.

In recent years it is understood that it is only the Surrey Coroner, Richard Travers, who has used his services on a regular basis, despite repeatedly being warned that his findings were wrong.

Mr Travers is even said to have asked Dr Heath to carry out a third post mortem on a body when the findings of his original report were heavily disputed by a second pathologist.

Both Surrey and Waltham Forest Councils said when his services were used, Dr Heath had an “unrestricted practising certificate issued by the GMC”.

Issues with coroners’ courts in this country are systemic

Last night, senior pathologists warned that the issues with coroners’ courts in this country are systemic and go much wider than one rogue doctor.

Sebastian Lucas, Emeritus Professor of Pathology at King’s College London, told The Telegraph: “The whole system is broken. One of the reasons for that is that there are no votes in death, no one in government cares.

“The most important change would be a little bit of oversight; if you asked most professionals what makes people do a good job they would say it is someone watching over you. You can’t be a bad surgeon and get away with it, but in mortuary pathology no one would necessarily know.”

In 2006 a group of pathologists and coroners reviewed thousands of autopsies for a report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), and found that a quarter were “poor or unacceptable” and one in five reported the wrong cause of death.

The report was referenced in a 2015 government review, which warned that Ministers had ignored the findings of previous inquiries and reviews and were missing an opportunity to fix “critical defects in the death investigation system”.

Prof Lucas said that the NCEPOD findings are still true today.  He has “a very good bird’s eye view of what’s going on” as he works on a number of confidential inquiries, including reviewing autopsies from all maternal deaths across England and Wales and reviews cases for lawyers, coroners and other pathologists.

His comments were backed by other pathologists, including Dr Christopher Milroy, who practised in England for more than two decades before moving to Canada where he continues to work in the field.

He called for Britain to implement the peer review system which is used in Ontario to ensure that there are checks and balances on a doctor’s work.

There are also calls for the number of mortuaries to be reduced from the current number of around 200 to around 50 professional regional centres to increase oversight.

One of the problems is that pathologists are paid less than £100 for an autopsy, a much lower rate than other countries, meaning there is a shortage of professionals.  

Dr Heath could not be contacted for comment. His “responsible officer” with the GMC, Dr Philip Dobson, who is charged with overseeing fitness to practice, said that he was unable to communicate the allegations to Dr Heath.

Dr Dobson, a cosmetic surgeon, did not respond to questions on how long he had oversight of Dr Heath’s career or what knowledge of pathology he had to be able to advise the GMC on his fitness to practice.

‘Doctor invented organ that wasn’t there’

When Alistair House read the report into his mother’s death, there was a rising sense of panic – had they cremated someone else’s body?

The pathologist described a gallbladder that Mr House knew his mother Ann had had removed, missed the scars of major surgery, and claimed that at just seven and a half stone she was “well nourished”.

But what the family did not realise at the time was that the post-mortem that they had been waiting for three month had been carried out by Dr Michael Heath, who had been discredited more than two decades earlier.

Mr House had originally called the Surrey Coroner Court about his mother’s death in August last year because he had major concerns about the care which she had received and believed that her death had been caused by neglect.

Mr House told The Telegraph: “When we finally got the report I started to go through it with a fine tooth comb. That’s when I started to spot inaccuracies. He failed to mention anything about my mother’s breast cancer, the scarring, or the fact that she had had half a lung removed, and mentioned that she had a perfectly healthy gall bladder”.

It was a consultant who had performed surgery on Mrs House, a retired social worker, who first questioned whether it was the right body.  

“We were really wondering whether we’d put the right body to rest”, Mr House said. “No one could give us an accurate answer we had to wait another six weeks to get any sort of clarification”.

He believes that it was the “flawed, inaccurate piece of work” which prompted the assistant coroner to close the inquiry into his mother’s death and any neglect she had suffered in hospital.

He said that Dr Heath should have been banned from practising decades ago. During his 20 years in animal health in the civil service if vets working for him had made “half of the mistakes Heath had they would have been struck off years ago”, Mr House said.

“I don’t know whether the GMC took the approach that he’s dealing with the deceased he is not really causing any harm, but he’s causing upset to the families, totally disrespecting the bodies of the deceased, and potentially covering up any issues at the NHS Trust’s that he’s been working alongside.”

‘We thought we’d buried the wrong body’

Amy Dickson (above) questioned the pathology report's finding and the stated cause of death as coronary heart disease

Credit:  Christopher Pledger

Amy Dickson was “floored” when the post-mortem report into the death of her father said that alcohol withdrawal symptoms had contributed to his death.

Stephen Goodenough had been an alcoholic all her life, and she was devastated that the one time he might have been about to give up alcohol she was not there, and it had killed him.

But the conclusion did not chime with anything that she knew about her father, or the scene that she had encountered at his Oxfordshire home after his death, which suggested he had suffered a massive haemorrhage.  

She questioned the finding and the cause of death as coronary heart disease.

When questioned by the Oxfordshire coroner’s office Dr Heath admitted that he had only included alcohol withdrawal as it had been mentioned that Mr Goodenough had been treated for it, but that was in 2013.

“When I read the report I thought that this was the time that he was going to give up. As a child of an alcoholic you live with this hope, and I thought what if this was the time that he was really going to do it”, Mrs Dickson said. “It was really, really just devastating.”

She believes that her 68-year-old father died of cirrhosis of the liver, caused by his drinking. But the family will never know for sure as they had him cremated whilst waiting for the post-mortem report, which took months.

“In a way, I need to know that he died from alcohol in that there is nothing that I can do about that. If my dad had died of a heart attack, if I had been there, I could have saved him”, she said.

When they read the post mortem it said that their 5ft 5in father was a “well built” man with a healthy liver, leading them to question whether it was even the right person.

“If you have got to the point that we did where you have got to phone the funeral home to get the dimensions of the coffin to make sure that you have cremated the right person then something has gone really, really wrong”, she said.

She said that Dr Heath should have been banned from all post-mortem work when he gave up working for the Home Office.

“You expect in these moments to be treated with dignity and respect. If he couldn’t be bothered to type up a word document properly, what on earth was he like with my dad’s body?” she asked.

“He was the last person to handle my dad, and to know that is horrible.”