A Manner of Fact.

How a death happened can be just as important as what caused the death. Yes, manner matters.

Take another look at the cause-of-death statement presented in the last installment of Practice Pearls. It was taken from an actual death certificate:

Part I.




A.                  Pneumonia-Aspiration poss.


Approximate interval: Onset to death


1 day

Due to (or as a consequence of):


B.                  Dysphagia


6 months

Due to (or as a consequence of):


C.                   Quadriplegia


3 years

Due to (or as a consequence of):


Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
Manner of Death



While aspiration pneumonia could result from dysphagia which in turn could be caused by quadriplegia, the question that should linger in the certifier’s mind is: What is the cause of the quadriplegia? Cervical spinal cord damage by Multiple Sclerosis? Epidural abscess complicating cervical disc surgery? A fall with fracture of the cervical spine and injury to the spinal cord? Or perforating injury to the cervical spinal cord from a remote gunshot wound? The manner of death for each of the four scenarios is very different: Natural vs Therapeutic Complication vs. Accident vs. Homicide. If the death circumstances are or might be accidental, homicidal, therapy-associated 1 or anything not associated with pure natural disease, the death must be reported to the ME/C. If you are a clinician certifier and list ‘quadriplegia’ or other non-specific terms as the underlying cause of death (the lowest line in Part I), expect to be notified by your friendly local Vital Stats professional (or your patient’s funeral home)!

Clinicians certify only natural deaths. Medical Examiners and Coroner (ME/C) physicians certify ALL manners of death.

For clinicians, accurate cause and manner of death determination flows from clinical diagnoses, clinical terminal events, and knowledge of the lethal potential of disease 2. For physician ME/Cs, this flows from comprehensive medicolegal death investigation, from scene to autopsy.

For both clinicians and ME/Cs, cause and manner of death determinations summarized in the cause-of-death section on the death certificate have important wide-ranging public health ramifications including increasing overall awareness of certain death trends with aims at death prevention or reduction in mortality rates 3-10. Examples include:

  • Deaths associated with medical procedures and devices: reports and bulletins compiled from data provided by online reporting
  • Fall injury deaths: identifying medical risk factors and in-home hazards
  • Traffic accident deaths: identifying road hazards, intervention by law enforcement regarding distracted or impaired driving
  • Opioid deaths: identifying sources of clandestinely manufactured fentanyl analogues, prompting changes in clinician prescribing habits and promoting alternate treatments for acute and chronic pain
  • Accidental drowning deaths: promoting and instituting measures regarding pool safety and safe boating
  • Homicide deaths of intimate partners-prevention through education in conflict resolution, offender intervention, improvement of services for domestic violence victims
  • Child homicide deaths: education of physicians, social workers, law enforcement and other mandated reporters in recognition of signs of abuse and the creation of integrated multi-agency standard operating procedures



  1. Armstrong E J. Chapter 8 Section 8.5: The Clinician Certifier of Death-Peri-procedural and Therapy-Associated Death Certification. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  2. Armstrong E J. Chapter 7: The Lethal Potential of Disease. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  3. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Available at: https://www.fda.gov/safety/medwatch/ .
  4. Fowler KA, Jack SPD, Lyons BH, et. al. Surveillance for Violent Deaths-National Violent Death Reporting System 18 States, 2014. MMWR Surveill Summ. 2018 ;67(SS-2):1-36. Available at: http://dx.doi.org/10.15585/mmwr.ss6702a1 .
  5. Centers for Disease Control and Prevention. Motor Vehicle Safety: Distracted Driving. Available at: https://www.cdc.gov/motorvehiclesafety/distracted_driving/index.html .
  6. Centers for Disease Control and Prevention. U.S. Drug Overdose Deaths Continue to Rise; Increase Fueled by Synthetic Opioids. Available at: www.cdc.gov.
  7. Centers for Disease Control and Prevention: Unintentional Drowning-Get the Facts. Available at: https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html .
  8. Centers for Disease Control and Prevention: Child Abuse and Neglect Prevention. Available at: https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html .
  9. National Coalition Against Domestic Violence Fact Sheet. Available at: https://www.speakcdn.com/assets/2497/domestic_violence2.pdf .
  10. Deaths from Falls Among Persons Aged ≥65 Years –United States, 2007-2016. MMWR 2018:67:509-514. Available at: http://dx.doi.org/10.15585/mmwr.mm6718a1 .


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