Throwing mud at the wall: Sometimes it just doesn’t stick!

The following death certificate did not pass the Vital Statistics “sniff test” and was sent to the local Medical Examiner’s office for review and amendment:

By all appearances, the patient had a number of serious health conditions. But which one killed the patient? The heart disease, the diabetes or perhaps the congestive heart failure? Did the spinal abscess causing cord compression and paralysis stem from a remote injury and therefore this really isn’t a natural death as was checked off in the manner-of-death section? How does that cause congestive heart failure? If somehow the paralysis with heart failure are linked and are the main cause of death, why is it listed in Part II instead of Part I?

By simply listing all of the patient’s major medical conditions, the laundry-list, catch-all approach to certifying this death missed the mark of identifying the one disease entity that triggered a series of interrelated complications that over time ultimately led to the death. Which International Classification of Disease (ICD) code applies in this death? More than one is represented. There can only be one.

Buzzwords like paresis and paralysis are red flags for injury as the possible underling cause. Injury and its complications fall under the domain of the Medical Examiner or Coroner (i.e. they are reportable deaths). Following a medicolegal investigation into the death circumstances, deaths resulting from injury will be classified as accident, homicide, or suicide.

An important question regarding the manner in which the spinal abscess with paresis was acquired remains- Gunshot wound to the spine? Intravenous injection of drugs with a dirty needle? Spinal trauma from a fall or a jump? Complication of spinal surgery…for an injury or a birth defect? Complication of natural disease like diabetes? Trends derived from manner of death classification have far-reaching important public health implications (1) .

1. National Vital Statistics System-Mortality Data. Available at:

More tips on de-mudifying the death certificate can be found in Chapter 8: The Clinician Certifier of Death from Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available at: .


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