From the Medical Examiner’s office: Common errors in death certification

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By Dr. Enrico Risso, Forensic Pathologist, Deputy Chief Medical Examiner

The death certificate is a legal document required for burial or cremation of the body. This document must be completed within 48 hours of death and is a permanent record providing documentation for legal and statistical purposes. If the death requires further investigation, the cause of death may be certified as “pending” and the final death certificate can be completed at a later time. The death certification should explain why the individual died, that is, what medical condition was most responsible for their death along with any other conditions that significantly contributed to the death.

The opinion provided by the certifying doctor is based upon training, medical knowledge, available medical history and diagnostic tests. Lack of appropriate death certification training and physician inexperience may lead to common errors in death certification, with subsequent repercussions on families, mortality statistics, public health research and distribution of public health resources. Inaccuracy in death certification is a well-recognized problem that may range from major errors in identifying the cause of death, to minor errors such as illegibility or incompleteness.

Uncertainty and inaccuracies in certifying the cause of death may result in possible amendments to the death certificate, legal inquiries and unnecessary post-mortem examinations. The latter scenario may occur if the document is used as a repository for all the medical conditions suffered by the patient without identifying the primary cause of death, or if trauma unrelated to death is listed as a cause of death or contributory factor.

The purpose of the death certificate is to obtain a logical description of the chain of events or process leading to the death. The primary and immediate cause of death (condition) that initiated the chain of morbid events leading to death should be entered in each line of the first part of the document (Part I). The second part (Part II) can accommodate more conditions that are regarded to be significant contributory factors, but did not result in the underlying cause listed in the first part. Part II should not be used to list all the medical conditions that were present at death.

When formulating the cause of death, the use of abbreviations and acronyms (e.g., F#, ACVD, HTN, and OA/OP) should be avoided, as this causes confusion and ambiguity. Non-specific terminal mechanisms, such as “cardiac arrest,” “respiratory arrest,” “arrhythmia,” “shock” or “heart failure,” should not be listed as primary diagnoses, as they represent the most common pathophysiologic mechanism concluding the sequence of events leading to death.