When something goes wrong in a patient's care : a death that shouldn't have happened, an outcome no one can quite explain , everyone in the room is reconstructing the story from the outside. The treating doctor is working from memory and notes. The family is working from grief and fragments of what they were told. The regulator or the court is working from a file. Only one person actually looked inside. The pathologist is, in effect, the last clinician to examine the patient.