Trial lawyers in personal injury cases frequently see death certificates within the (sometimes) voluminous pages of medical records at issue. The death certificate may be critical in a lawsuit for many reasons, not the least of which is potential liability, as well as the nature of the death, contributing factors to the death, the timeframe of the death, and illnesses that may have impacted the death but not directly caused it.
But how reliable is the death certificate, the document in which so many place their faith and legal filing fees? Maybe not as much as we would like to think.
What’s the form for?
The death certificate is a medical record and a legal document, the primary purpose of which is to show that a person has died. Other major purposes are to: (a) provide information for mortality statistics that may be used to assess the Nation’s (and the State’s) health; (b) register causes of morbidity and mortality; and (c) develop funding and programs for public health and safety issues.
To serve these purposes, individual states have a death certificate form based on the US Standard Certificate of Death, and while the documents can vary slightly, they are largely similar as they are required to report certain elements such as date, time, location and cause of death, as well as manner of death. According to Dr. Randy Hanzlick at the National Association of Medical Examiners (NAME), one of the authors of A Guide for Manner of Death Classification, the manner of death designation is an “American invention” that was added to the US Standard Certificate of Death by public health officials in 1910, primarily to assist in clarifying the circumstances of death and to help those who “code and classify cause-of-death information from death certificates for statistical purposes.” In most states, the options are: Natural; Accident; Suicide; Homicide; and Undetermined/Cannot be Determined.
What’s the form worth?
Death certificates are only truly useful for any of their purposes if they are accurate. There are studies on the inaccuracy of death certificates going back decades, as well as very recently. See here for a few. Hanzlick’s guide, above, notes that, “In general, the death certificate serves as legal proof that death has occurred, but not as legal proof of the cause of death.”
Indeed, in the Krywanczyk study mentioned below:
“In 12 months, 590 death certificates were issued by the hospital. Eighty-eight of 590 (15%) were amended. Of those 88 amended, 41 (47%) were missing an underlying cause of death, 7 (8%) had an inaccurate cause of death, 41 (47%) failed to include relevant contributory causes of death, and 17 (19%) had major typographic errors. Of 88, 24 (27%) fell under the Office of the Medical Examiner’s jurisdiction and were reported with a subsequent change in the manner of death in 23 of 88 cases (26%).”
This is in the United States, within the last three years. WHY can death certificates be inaccurate?
The person who certifies death is usually the treating physician or the hospice or palliative care physician. Some certificates are signed by a patient’s primary care physician, a medical examiner, a coroner, or a forensic pathologist, depending on state law. In Texas, a justice of the peace can sign the death certificate; in North Carolina, a physician’s assistant or nurse practitioner can sign the death certificate, if authorized by his or her supervising physician.
A coroner is an elected official and is usually not a medical doctor (unless a physician is elected to the position) and they do not usually have medical training. The same goes for a justice of the peace. If a person is deceased due to a gunshot wound or a car accident, that may be an obvious conclusion, but for determining a disease or illness that caused a person’s death, it does not seem these officials would be the best decision makers on cause of death.
Even those with medical training may not know much about the patient whose death they are certifying. If a patient has been placed in a palliative care setting, the physician may not know much about his or her medical history, and may not be caring for the patient very long. If this physician signs the death certificate, it may very well have inaccuracies simply because the doctor did not know the patient well enough or long enough. The same is true for a patient who comes in through the emergency department and dies without an obvious cause.
Look before you lawyer…
If your causation or damages argument is hinging on the cause of death listed on a death certificate, you might want to look into a few of the circumstances surrounding the signing of it.
Flagg LA, Anderson RN. Unsuitable Underlying Causes of Death for Assessing the Quality of Cause-of-death Reporting, National Vital Statistics Reports, Vol. 69, No. 14, January 11, 2021
Krywanczyk A, Amoresano E, Tatsumi K, Mount, S. Autopsy Service Death Certificate Review: An Educational Experience and Public Health Service, Arch Pathol Lab Med. 2020;144:1092–1096
Schuppener LM, Olson K, Brooks EG. Certification: Errors and Interventions, Clinical Medicine & Research, 2020; Volume 18, Number 1:21-26
D’Amico, Agozzino E, Biagino A, Simonetti A, Marinelli P. Ill-defined and multiple causes on death certificates--a study of misclassification in mortality statistics, Eur J Epidemiol, 1999 Feb;15(2):141-8
Myers KA, Farquhar DR. Improving the accuracy of death certification, CMAJ, 1998 May 19; 158(10):1317-23
Nielsen GP, Björnsson J, Jonasson JG. The accuracy of death certificates. Implications for health statistics, Virchows Arch A Pathol Anat Histopathol, 1991;419(2):143-6.