Certification of Cause of Death

For a death to be considered medically certified, a clinician must complete the register of death
and judge what causes led to death. This can only be done by a medically trained person who
fully understands the clinical sequence of conditions and, therefore, can determine the single
underlying cause of death which initiated the fatal sequence. Clinicians, therefore, have a vital
role to play in the production of high quality mortality data by ensuring complete, accurate and
detailed information is recorded on the register. Therefore it is important they are trained on
filling in the medical certificate of cause of death.

Definition of causes of death

 All those diseases, morbid conditions or injuries which either resulted in or

contributed to death and the circumstances of the accident or violence which
produced any such injuries.
 It does not include symptoms and modes of dying, such as heart failure or respiratory
failure.
 Cause of death is required for the purpose of mortality tabulation and statistical use.
 Several causes can be attributed to the death but only one cause needs to be identified
and selected based on the principles of preventing the primary or underlying cause of
death had there been effective preventive programs. This is the basis of the WHO
principle of the underlying cause of death, which resolves the situation where there
are several causes to a one death-one cause situation.

Mortality statistics are based on the underlying cause of death defined as the disease which
initiated the chain of events leading directly to death or the circumstances of the accident or
violence which produced the fatal injury. For example, a person dying of cerebral haemorrhage
following a motor vehicle accident; cerebral haemorrhage is the direct cause of death - the motor
vehicle accident is the underlying cause of death.
The immediate cause of death is the terminal event that occurred, just before the death. Mode
of death such as respiratory failure, heart arrest, or brain death etc. should NOT be considered as
the underlying cause of death.

The international form of medical certificate of cause of death

The WHO international form of medical certificate of cause of death (figure 1) is designed to
help clinicians report the causes and conditions that led to a person’s death. The form includes
demographic information used in collating statistics on causes of death, the extract in figure 1
shows only the cause of death component of the certificate which consists of two parts:
Part I of the form has 4 lines which represent the causal chain of death. It isused to fill the
sequence of events leading to death; these are labeled (a) to (d). The immediate cause of death is
entered at Part I(a). If the death was a consequence of another disease or condition, this
underlying cause should be entered at I(b). If there are more events leading to death, write this in
order at I(c) and I(d).It is important to:

- Always use consecutive lines, never leave blank lines within the sequence of events.
- Each condition listed in Part I should cause the condition above it.
- If there is only one cause of death, it is entered at I(a).

Part II is used to record all other significant or contributory diseases or conditions that were
present at the time of death, but did not directly lead to the underlying cause of death listed in
Part I.

A column on the right hand cuts across Parts I and IIis used to recordthe interval between onset
of the condition and date of death. The time interval should be entered for all conditions reported
on the certificate, especially for conditions reported in Part I. These intervals are usually
established by the clinician on the basis of available information and in some cases will have to
be estimated. Time periods such as minutes, hours, days, weeks, months or years can be used.

If the time of onset is unkown or cannot be determined, write “Unknown”.

Figure 1: The International form of medical certificate of cause of death

INTERNATIONAL MEDICAL CERTIFICATE OF CAUSES Approximate

OF DEATH CAUSE OF DEATH Interval
PART I between on set
and death
Disease or Condition directly (a).......................................................... ...........................
Leading to death* Due to (or as a consequence of)
..............
Antecedent causes (b).......................................................... ...........................
...........
Morbid conditions, if any, Due to (or as a consequence of)
Giving rise to the above cause, (c).......................................................... ...........................
Stating the underlying condition ...........
last Due to (or as a consequence of)
(d).......................................................... ...........................
...........

.............................................................. ...........................
Other significant conditions
Contributing ..........
PART II to the death, but
Not related to the disease or
Condition causing it
............................................................. ..........................
...........
injury
*This or complication
means which
the disease,
Caused the death. It does NOT
mean
The mode of dying, such as heart
or
respiratory failure

When completing the medical certificate of cause of death the following applies when recording
the underlying cause of death:
 The condition recorded on the lowest line of part I should be the underlying cause of
death.
 It is possible that a cause listed on another line is the underlying cause if the
certificate is not completed correctly
 It is valid to have a certificate of cause of death using only one line if there is only
one step in the chain of events leading to death.

Before completing a certificate of cause of death

  Completeness of information: review all of the information recorded in the patient
notes identifying information about the deceased including age, sex, and place of
death, the narrative history of the illness symptoms, with their durations, details of
past medical illness. Other information includes evidence from laboratory test reports,
prescriptions, and other medical documents, and health services used by the deceased
during illness in a period before death.
 Take into account the absence of a symptom or sign
 Write the relevant key information and select the key words in the history. Look for
cardinal symptoms and signs. Consider any significant negative evidence, similar to
the classical teaching of clinical history taking and diagnosis.
 Put the key words in chronological and pathophysiological sequence.
 Lastly come up with a tentative sequence of diagnosis and put them in the appropriate
lines.

In filling out the certificate, clinicians should try to identify and record all the conditions in the
sequence of events leading to death. For many deaths, there will be more than one cause and, in
these cases, the clinician will need to establish a sequence of causes before determining the
underlying cause.
Universality: the certificates of cause of death that are generated should meet the WHO
standards by applying the principles and rules that are universally applicable.

Definitions in Certification of Cause of Death

When a person dies, the meaning of the different steps that need to be followed and documents
that need to be issued can cause confusion. It is important to distinguish between death
notification, death registration, death certification and medical certification, and make sure that
the appropriate forms are available for each process.

Notification occurs when an appropriate authority (assistant chief or health worker) issues a
form confirming that a death has taken place. Health workers are responsible for notifying events
that occur in their respective health facility; assistant chiefs are responsible for notifying events
that occur at home or in the community. The notification form is often needed for the burial to
take place and for formally registering the death.

Medical certification occurs when a clinician completes the certificateof cause of death;
declaration which states the cause of death. This serves a number of functions including enabling
the deceased family to register the death legally.

Clinical Coding is the process of translating the diagnosis or diagnostic statement into an
alphanumeric code in reference to International Classification of Diseases.
Registration occurs when a civil registrar formally registers the death at the civil registration
office. If the death has not been registered, a legally valid death certificate cannot be issued.

Certification occurs when the civil registrar issues the legal death certificate, which is needed
for inheritance, insurance purposes and other claims. It serves as a permanent legal record of the
death.

Who certifies the cause of death?

This is the responsibility of a medical practitioner or/and any other person authorized by law. In
the event that a patient dies in a hospital or medical facility, it is the statutory duty of the
clinician who has attended in the last illness to issue the medical certificate of cause of death
.There is no clear legal definition of “Attended”, but it is generally accepted to mean a clinician
who has cared for the patient during the illness that led to death and so is familiar with the
patient’s medical history, investigations and treatment.

The certifying clinician should also have access to relevant medical records and results of
investigations. In a hospital, there may be several clinicians in a team caring for the patient. It is
ultimately the responsibility of the clinician in charge of the patient’s care to ensure that the
death is properly certified. Any subsequent enquiries should be addressed to the clinician in
charge.

If a person dies at home, the register of death is completed by the assistant chief and submitted to
the registrar.

Death registration process in Kenya

The notification process involves the registration assistant, health worker or assistant chief,
entering information on the official registration form (figure 2). The form has two parts that
contain a matching serial number; a detachable section called permit for burial and a register of
death. After completing the form, the registration assistant retains the counterfoil copy of the
burial permit and gives the original slip to deceased’s family or next of kin as proof of
notification, which they later submit to the civil registrar to obtain a legal death certificate. The
form must state the causes that led to death and must be written in a way that a coder can read
the writing and assign appropriate codes. The clinician certifies the cause of death in the section
labelled “medical certification”. The HRIO assigns an ICD-10 code to every condition stated on
the form. The registration assistant sends the completed registration form, including the original
and duplicate, to the civil registrar who retains the counterfoil of the duplicate. At the civil
registration office the forms are verified, legally recognized (registrar appends signature), duly
recorded, and assigned a unique personal identification number. This constitutes legal
registration, and only after this step can a legal certificate be issued to the family or next of kin.
To obtain a legal certificate, the family or next of kin takes the burial permit to the civil
registration office, which then searches for the original registration form submitted by the
registration assistant, filed by the serial number. The registrar will confirm the applicant’s
personal identity and issue the legal death certificate.
Figure 2: The Kenya death registration form (D1)