On the Edge.

Imagine if you were unable to:

  • bury or cremate a loved one,
  • arrange an out-of-state funeral,
  • activate a life insurance policy,
  • access or close a bank account,
  • pay your mortgage or utility bill,
  • sell your house or car,
  • probate a will,
  • or settle an estate

…all while grieving the loss of a loved one and teetering along the balance beam of family and work life. These are examples of what many families and caretakers endure when a death certificate is delayed 1, 2, 3 .

On a regular basis, responsibility for the certification of a natural death is deferred to the medical examiner or coroner (ME/C) when the physician of record or the pronouncing physician declines to certify the death 4.  In these instances and because many ME/C offices still do not have access to electronic medical records, a request for records will be necessary. These include records from hospitals, hospice facilities, nursing homes, short- and long-term care rehabilitation facilities, and clinics. While records are received by fax and increasingly by email, days or weeks may transpire before they are received, further delaying the certification of the death.  It may be necessary to issue a pending death certificate within the mandated time frame as required by state law. Once received, records will be reviewed and interpreted by the forensic pathologist or the physician medical examiner or coroner followed by determination of the cause of death with completion of the final death certificate. The performance of any postmortem testing may cause additional delay to completion of the final death certificate.

Over-burdened, understaffed ME/C’s offices already struggle with timely certification of jurisdictional deaths in the face of the current opioid crisis and an uptick in the number of homicides in some locales and are acutely aware of the hardships faced by families waiting for the death certificate to be completed 5.


  1. http://fox59.com/2015/03/19/fox-59-investigates-death-certificate-delay-costing-family-thousands/
  2. http://www.kctv5.com/story/34324924/kansas-city-widow-waits-6-weeks-for-death-certificate
  3. http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/death-certificate-process-and?page=full
  4. https://www.bostonglobe.com/business/2014/06/16/grieving-families-face-insurance-financial-problems-from-delays-state-death-certificates/CdqKPttNPvoDncewrajliN/story.html
  5. http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/07/06/opioid-overdose-deaths-swamp-medical-examiners

A wise fortune teller sees a Practice Pearls in the crystal ball of your future. Stay tuned!


Game on! Show what you know and take the “5 for 5 Challenge Book Giveaway” with direct access by this link: https://www.linkedin.com/pulse/5-challenge-book-giveaway-erica-j-armstrong-md/ and win a FREE postage paid one of these!


Hint: Information pertinent to  the questions (aka-the answers) can be found in the Practice Pearls posts from July 2, July 16, Sept. 10 and Sept. 24.


Seriously, you’d pass on a freebee?!?

“Oh, What A Tangled Web…”

A true story…

Case Scenario: A middle-aged man dies in a nursing home of acute pneumonia with sepsis and respiratory failure. He had a recent history of a gunshot wound (site not specified), quadriplegia, and basocranial and facial skeletal fractures, all of unknown circumstance(s).

Surely this death was reported!-you exclaim.

In actuality… it was not.

Instead, nearly 2 weeks transpired until this death was reported, not by the nursing home, not by a first funeral home, but by a very astute second and final funeral home, luckily, prior to any further funeral proceedings such as a burial or a cremation of the body.  An autopsy was definitely needed followed by amendment of the heretofore completed death certificate.

When examined alone, the terminal disease conditions of the case scenario are suggestive of natural disease sequelae. The risk: The death will be not be reported but instead certified by the clinician as such with classification of the manner of death as natural. When examined in the context of his overall health status and medical history, the realization should be that a connection could exist: That the terminal disease conditions actually represent the delayed complications of prior injury.  A death in which the terminal clinical course could represent delayed complications of injury, regardless of the time interval, is a reportable death, an important point for all clinical practitioners to keep in mind. A medicolegal autopsy which includes review of all pertinent medical records is necessary to either confirm or discount a connection between disease and injury.

Furthermore, autopsy findings and medical record information may reveal circumstances suggestive of foul play or homicidal violence or otherwise unknown non-natural circumstances requiring further investigation by law enforcement. If circumstances suggestive of foul play or homicidal violence are discovered, a potentially crucial time period has already transpired during which there may have been loss of vital evidence, investigative leads, and access to potential witnesses to the death circumstances.

The serious disservice to society is for a death involving homicidal violence or resulting from reckless or negligent acts to escape adjudication because of a failure to report.


Now to unravel the mystery of the last PPQ:

The death certificate was flagged for many, many reasons and furthermore, the death was reportable.  The reasons:

  1. Use of non-specific terminology with possible non-natural (traumatic) causes: septic shock, bacteremia, wound, acute kidney injury
  2. Listing of more than one condition and competing conditions per line (line a.)
  3. Use of abbreviations (CHF)
  4. Lack of medically known cause-and-effect relationship between lines a-d: examples- acute kidney injury does not cause severe aortic stenosis and severe aortic stenosis does not cause severe pulmonary hypertension
  5. Listing a range of calendar dates in “Approximate interval: Onset to death” box (Use of terms such as seconds, minutes, hours, days, weeks, years, and decades with or without specific numbers, inclusion of qualifiers such as “approximately”, or if interval not known “unknown” are permitted. Boxes with corresponding cause of death information cannot be left blank.)

Stay tuned for a future Practice Pearls!



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