“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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