Guide to Handling Injuries, Poisonings, and External Causes of Death in Coronial Systems
Session 6: Certifying
external causes of death
Training Workshop on Medical certification of cause of death
•
In countries where coronial system is in place doctors may need to
inform the coroner about deaths from causes in this category before
completing the MCCD
•
These are often referred to as "unnatural deaths"
•
What are the
instructions in your own country?
Injuries, Poisonings and External
causes of death
•
If
there
is
a
n
attending
medical
officer
at
death,
the
certifying
officer
is
the
attending
medical
officer/physician
•
If
there
is
no
attending
medical
officer
at
death
the
certifying
officer
is
the
Local Health
Officer
•
In
medico-legal
cases,
the
certifying
officer
is
the
medico-
legal
officer
/Judicial Medical Officer
•
How about your country?
Who certifies/documents the
MCCD?
I
n
j
u
r
i
e
s
,
P
o
i
s
o
n
i
n
g
s
a
n
d
E
x
t
e
r
n
a
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a
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s
e
s
o
f
d
e
a
t
h
…
D
e
a
t
h
w
i
t
h
M
e
d
i
c
o
-
L
e
g
a
l
I
m
p
l
i
c
a
t
i
o
n
s
Local
Civil
Registrar
Local
Health
Officer
M
e
d
i
c
o
-
l
e
g
a
l
i
n
v
e
s
t
i
g
a
t
i
o
n
A
l
w
a
y
s
f
o
l
l
o
w
t
h
e
l
o
c
a
l
i
n
s
t
r
u
c
t
i
o
n
s
&
t
h
e
p
r
o
c
e
s
s
•
The
classification
of;
•
environmental
events,
•
circumstances
and
•
conditions
as
the
cause
of
injury,
poisoning
&
other adverse
effects.
For certification we are interested in:
•
The injury
•
The mechanism (what is the external cause)
•
The intent (accident, suicide, homicide)
The external cause concept
•
Patient is usually treat
ed
by doctor for the
I
mmediate cause
/
Terminal event
of death (e.g. Intracranial
h
emorrhage, ruptured
liver, effect of the poison
etc.
)
•
When death occurs as a consequence of injury or violence, the
mechanism
(the circumstance of the injury) should
always
be
listed as the underlying cause.
Injuries, poisonings and external
causes of death…
Death
resulting
from cerebral
compression
due to subdural
haematoma
after
a
fall
from
a
tree
Example - 1
Underlying cause
of death
Immediate cause
of death
Terminal Event
Starting Point
Sequence of events leading to
death
Deaths due to External Causes
•
Injuries
are some of the most poorly certified causes of death in the Pacific
Islands.
•
Most end up as “injury – non-specified”
•
In order to record the underlying cause of death we need both:
1. THE INJURY
1. THE INJURY
+
+
2. HOW THE INJURY OCCURRED
2. HOW THE INJURY OCCURRED
+
+
3.
3.
THE MANNER OF THE DEATH
THE MANNER OF THE DEATH
The
external cause
should
be
described
in as
much
detail
as
possible;
•
f
o
r
e
x
a
m
p
l
e
,
‘
m
o
t
o
r
t
r
a
f
f
i
c
a
c
c
i
d
e
n
t
’
i
s
n
o
t
s
u
f
f
i
c
i
e
n
t
l
y
a
c
c
u
r
a
t
e
;
•
h
o
w
e
v
e
r
,
‘
p
e
d
e
s
t
r
i
a
n
h
i
t
b
y
m
o
t
o
r
c
a
r
i
n
a
p
u
b
l
i
c
h
i
g
h
w
a
y
’
i
s
b
o
t
h
c
l
e
a
r
&
a
c
c
u
r
a
t
e
.
Injuries, poisonings and external
causes of death…
1. The INJURY
EXAMPLES
•
Bleeding from a head wound
•
Poisoning
•
Crush injury to chest
Medical certificate examples:
•
In both cases we need MORE information on
how the injury occurred
how the injury occurred
1.
Exsanguination
2.
Penetrating stab
1.
Toxic shock due to
2.
Septicaemia
3.
Infected wound (right leg)
2. HOW the INJURY OCCURRED
EXAMPLES INCLUDE
•
Ingestion of chemical/ fish/ etc - specify what was ingested if known
•
Stabbing wound
•
Hanging
•
Drowning
•
MVA - detail of the type of vehicle, and passenger/driver/ pedestrian if
possible.
•
Fall – specify if this was a fall off something or something falling onto them
and what this object was
2. HOW the INJURY OCCURRED
(cont’d)
Medical certificate examples:
1.
Toxic shock due to
2.
Septicaemia
3.
Infected wound (Right leg)
4.
Crush injury from Motor
bike crash
1.
Exsanguination
2.
Penetrating stab
wound to abdomen
3.
Spear gun injury
3. Manner of death
•
Should be recorded for all external causes
•
Options are:
•
(NATURAL)
•
Accidental
•
Intentional self harm
•
Assault
•
Legal intervention
•
Not known
•
Common issues include:
•
Hanging (should only be counted as suicide if this is specifically noted)
•
Drowning
•
Poisoning (very different codes for accidental ingestion vs deliberate self- harm); however “not known” ends up
in a separate category of “injury – other” in the General mortality list
3. MANNER Of DEATH
Medical certificate examples
:
UCOD: Motorbike crash
UCOD: Accidental injury
1.
Toxic shock due to
Septicaemia
2.
Infected wound (Right leg)
3.
Spear gun injury
4.
Crush injury from Motor
bike crash (accident)
1.
Exsanguination
2.
Penetrating stab wound
to abdomen
3.
Spear gun injury
(accident – self inflicted)
3. Manner of death
•
Unless legislation has assigned determining the manner of death elsewhere
(such as a coroner or police investigation), this should be included on the
medical certificate by the certifying doctor – to the best of their ability
•
Things to consider when determining the ‘manner of death’:
•
The type, location and characteristics of the injury itself
•
Documented history (ie previous self-harm intents)
•
Family report/ witnesses etc
•
Evidence of intent to act (saying goodbye, closing accounts etc)
•
Where there is concern (e.g. Assault) – follow local policy on referring cases
to medical supervisor and/or police
POISONING
(intentional vs Non-intentional)
•
Multiple possibilities when someone is recorded as having died from
“poisoning”
•
This usually means either:
•
Accidental – ingestion of chemical or toxic substance (child ingesting cleaning
fluid, mushrooms, fish toxin), smoke inhalation, overdose of a recreational drug
etc.
•
Intentional self-harm - i.e. paraquat poisoning
•
Adverse effect in medical care (e.g. anaesthetic reaction)
•
The substance and means by which it was consumed (ingested/
inhaled/ injected etc) should be noted if known; as well as the intent.
Poisoning
Poisoning
Alcohol
•
Alcohol is a leading cause of morbidity and mortality
•
While it can cause death due to an acute poisoning it is more common
that alcohol use leads to long term health problems
•
This means it can be left off the certificate
•
Add alcohol use, including as the underlying cause of death if a factor
in death
Alcohol
Injuries, Poisonings & External causes of
death
•
In a case of suicide, simply entering ‘suicide’ is insufficient; the
method of suicide should be entered
•
For example, ‘Suicidal death by hanging’ is a clear description
•
Certifying suicide can be a sensitive and difficult issue
- deaths are considered preventable
- more likely to occur in younger people
- data is important for public health interventions
•
Any country sensitivities to note?
Deaths due to a Natural disaster
•
When a death occurs due to a natural disaster – the cause should be
specified as normal.
•
However if the physician believes that the death was related to the
natural disaster -this should be recorded in the contributory causes
•
The collection of statistics on the impact of a natural disaster is
essential, but often this information cannot be obtained from the
Health services and comes from unverified reports through the
Emergency Management System.
R
e
s
o
u
r
c
e
s
CDC Medical examiners handbook
https://www.cdc.gov/nchs/data/misc/hb_me.pdf
CDC guidelines for determining suicide:
https://www.cdc.gov/mmwr/preview/mmwrhtml/00001318.htm
US instructions for completing the medical certificate in cases of injury or
poisoning (external causes)
https://www.cdc.gov/nchs/data/dvs/red_form.pdf
US instructions for completing the medical certificate after hurricanes
https://www.cdc.gov/nchs/data/dvs/hurricane_certification.pdf
In countries with a coronial system, doctors must report deaths from unnatural causes to the coroner before completing the MCCD, known as "unnatural deaths." Certification and documentation of the MCCD vary based on the presence of attending medical officers or medico-legal officers. Understanding the external cause concept is crucial, including injury mechanisms and intents. Properly listing the underlying cause in cases of death due to injury or violence is essential. Follow local instructions and procedures for medico-legal investigations.
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Presentation Transcript
Injuries, Poisonings and External causes of death In countries where coronial system is in place doctors may need to inform the coroner about deaths from causes in this category before completing the MCCD These are often referred to as "unnatural deaths" What are the instructions in your own country?
Who certifies/documents the MCCD? If there is an attending medical officer at death, the certifying officer is the attending medical officer/physician If there is no attending medical officer at death the certifying officer is the Local Health Officer In medico-legal cases, the certifying officer is the medico- legal officer/Judicial Medical Officer How about your country?
Injuries, Injuries, Poisonings Poisonings and and External External causes of causes of death death
Death with Medico-Legal Implications Local Health Officer Local Civil Registrar Always follow the local instructions & the process Medico-legal investigation
The external cause concept The classification of; environmental events, circumstances and conditions as the cause of injury, poisoning & other adverse effects. For certification we are interested in: The injury The mechanism (what is the external cause) The intent (accident, suicide, homicide)
Injuries, poisonings and external causes of death Patient is usually treated by doctor for the Immediate cause / Terminal event of death (e.g. Intracranial hemorrhage, ruptured liver, effect of the poison etc.) When death occurs as a consequence of injury or violence, the mechanism (the circumstance of the injury) should always be listed as the underlying cause.
Example - 1 Death resulting from cerebral compression due to subdural haematoma after a fall from a tree
Sequence of events leading to death Death Death Terminal Event Immediate cause of death Cerebral Cerebral compression compression Subdural Subdural Haematoma Haematoma Underlying cause of death Starting Point Fall from a tree Fall from a tree
Deaths due to External Causes Injuries are some of the most poorly certified causes of death in the Pacific Islands. Most end up as injury non-specified In order to record the underlying cause of death we need both: 1. THE INJURY + 2. HOW THE INJURY OCCURRED + 3. THE MANNER OF THE DEATH
Injuries, poisonings and external causes of death The external cause should be described in as much detail as possible; for example, motor traffic accident is not sufficiently accurate; however, pedestrian hit by motor car in a public highway is both clear & accurate.
1. The INJURY EXAMPLES Bleeding from a head wound Poisoning Crush injury to chest Medical certificate examples: 1. Toxic shock due to 2. Septicaemia 3. Infected wound (right leg) 1. Exsanguination 2. Penetrating stab In both cases we need MORE information on how the injury occurred
2. HOW the INJURY OCCURRED EXAMPLES INCLUDE Ingestion of chemical/ fish/ etc - specify what was ingested if known Stabbing wound Hanging Drowning MVA - detail of the type of vehicle, and passenger/driver/ pedestrian if possible. Fall specify if this was a fall off something or something falling onto them and what this object was
2. HOW the INJURY OCCURRED (cont d) Medical certificate examples: 1. Toxic shock due to 2. Septicaemia 3. Infected wound (Right leg) 4. Crush injury from Motor bike crash 1. Exsanguination 2. Penetrating stab wound to abdomen 3. Spear gun injury
3. Manner of death Should be recorded for all external causes Options are: (NATURAL) Accidental Intentional self harm Assault Legal intervention Not known Common issues include: Hanging (should only be counted as suicide if this is specifically noted) Drowning Poisoning (very different codes for accidental ingestion vs deliberate self- harm); however not known ends up in a separate category of injury other in the General mortality list
3. MANNER Of DEATH Medical certificate examples: 1. Toxic shock due to Septicaemia 2. Infected wound (Right leg) 3. Spear gun injury 4. Crush injury from Motor bike crash (accident) 1. Exsanguination 2. Penetrating stab wound to abdomen 3. Spear gun injury (accident self inflicted) UCOD: Motorbike crash UCOD: Accidental injury
3. Manner of death Unless legislation has assigned determining the manner of death elsewhere (such as a coroner or police investigation), this should be included on the medical certificate by the certifying doctor to the best of their ability Things to consider when determining the manner of death : The type, location and characteristics of the injury itself Documented history (ie previous self-harm intents) Family report/ witnesses etc Evidence of intent to act (saying goodbye, closing accounts etc) Where there is concern (e.g. Assault) follow local policy on referring cases to medical supervisor and/or police
POISONING (intentional vs Non-intentional) Multiple possibilities when someone is recorded as having died from poisoning This usually means either: Accidental ingestion of chemical or toxic substance (child ingesting cleaning fluid, mushrooms, fish toxin), smoke inhalation, overdose of a recreational drug etc. Intentional self-harm - i.e. paraquat poisoning Adverse effect in medical care (e.g. anaesthetic reaction) The substance and means by which it was consumed (ingested/ inhaled/ injected etc) should be noted if known; as well as the intent.
Alcohol Alcohol is a leading cause of morbidity and mortality While it can cause death due to an acute poisoning it is more common that alcohol use leads to long term health problems This means it can be left off the certificate Add alcohol use, including as the underlying cause of death if a factor in death
Injuries, Poisonings & External causes of death In a case of suicide, simply entering suicide is insufficient; the method of suicide should be entered For example, Suicidal death by hanging is a clear description Certifying suicide can be a sensitive and difficult issue - deaths are considered preventable - more likely to occur in younger people - data is important for public health interventions Any country sensitivities to note?
Deaths due to a Natural disaster When a death occurs due to a natural disaster the cause should be specified as normal. However if the physician believes that the death was related to the natural disaster -this should be recorded in the contributory causes The collection of statistics on the impact of a natural disaster is essential, but often this information cannot be obtained from the Health services and comes from unverified reports through the Emergency Management System.
Resources CDC Medical examiners handbook https://www.cdc.gov/nchs/data/misc/hb_me.pdf CDC guidelines for determining suicide: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001318.htm US instructions for completing the medical certificate in cases of injury or poisoning (external causes) https://www.cdc.gov/nchs/data/dvs/red_form.pdf US instructions for completing the medical certificate after hurricanes https://www.cdc.gov/nchs/data/dvs/hurricane_certification.pdf
