To Report or not to Report? That Is the Question.

Which of the following would you report to the Medical Examiner or Coroner?

A 62 year-old woman with ischemic heart disease develops progressive heart failure subsequent to a hip fracture sustained 6 months prior. She never returned to baseline and dies while in the rehabilitation care facility.

A 45 year-old woman is hospitalized for a severe asthma exacerbation triggered after smoking crack cocaine. The urine drug screen is positive for cocaine metabolites. She develops anoxic encephalopathy, acute bronchopneumonia, and respiratory failure and expires on hospital day 7.

A 55 year-old man dies of multisystem organ dysfunction due to polymicrobial urosepsis after a brief hospitalization. Fifteen years prior, he sustained a spinal cord injury from a fall with resultant paraplegia. He developed a neurogenic bladder requiring intermittent catheterization and has had recurrent urinary tract infections ever since.

In each of these scenarios, natural disease seems to be the proximate cause of death; however; they all involve non-natural triggers and are all reportable. Deaths due to the acute or delayed effects of injury or intoxicants are reportable regardless of the interval of time that has transpired.  A whole host of complications disguised as chronic medical conditions have potentially non-natural causes. Examples of these include bowel adhesions, decubital ulcers, and seizures. It is important to not lose sight of the root cause of chronic medical conditions as this may preclude reporting of a death that should be reported. The temporal association of the effects of injury and intoxication will be the determining factor in the classification of the death as a homicide, suicide, or accident which is done by the Medical Examiner or Coroner. Clinicians certify only purely natural deaths.

Examples of other reportable deaths include:

  • Deaths occurring within 24 hours of hospital admission (clinical definition of sudden death)
  • Peri-procedural or therapy-associated deaths
  • Deaths of group home or institutionalized residents

Reporting deaths to the Medical Examiner or Coroner requires communication of key pieces of information. The Medical Examiner or Coroner will take jurisdiction and investigate certain deaths as mandated by state law.

For more information, see Chapters 3, 7, and 8 of Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

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Not My Job: Misconceptions of Death Certification

Amongst the ever-expanding demands on the clinical practitioner, death certification may seem like just another onerous task to tick off the long list of duties that have little to do with real patient care. The assumption may be that it’s just optional and nothing will happen if a death is not certified. Or perhaps that the certification of death is really not that important and therefore not a priority. The fact is, death certification is an important patient care duty and so much more.

Aside from serious financial and emotional distress that a family may be forced to endure, a delayed or uncompleted death certificate triggers a cascade of real-life consequences that ultimately affects us all. So important is mortality data for the global optimization of health that the World Health Organization (WHO) has standardized the way it is to be collected by the participating nations for the purpose of international health comparisons. In the US, the Centers for Disease Control and Prevention-National Center for Health Statistics (CDC-NCHS) along with the National Vital Statistics System (NVSS) provide oversight and guidance for the standardized collection of mortality data from death certificates.  A multitude of federal, state, and other local agencies utilize statistical data derived from death certificates to facilitate epidemiological study, health monitoring, healthcare fund allocation, law-making, and social and medical research.

Certain misconceptions regarding death certification exist amongst clinical practitioners that lead to unnecessary delay which is a disservice to the bereaved family or the legal representative of the deceased and to public health surveillance efforts. Some of the more prominent ones follow:

  • Only the Attending Physician or the decedent’s primary care physician is authorized to complete and sign the death certificate
  • The physician will be penalized for listing an incorrect cause of death
  • The Medical Examiner or Coroner is responsible for completing and signing all death certificates clinicians fail to complete and sign

More myth-busting information on this topic can be found in Chapter 8 of Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available at

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