1. Cause of death documentation, are we getting it right?
A case study of cause of death documentation available from death certificates in a teaching hospital in Ghana.

2. Outline Introduction Methods Results Discussion Conclusions
Recommendations
References

3. Introduction
The most effective public health intervention to prevent death, is to prevent the underlying cause of death (UCoD) from occurring.
Accurate and reliable information on UCoD needed for policymakers/health authorities to implement interventions to decrease morbidity and mortality.
Are we providing policymakers with accurate and reliable statistics on the underlying causes of death (UCoD)?

4. Introduction The Underlying Cause of Death (UCoD) is:
“(a) the disease or injury which initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury”.(WHO,2010)
Etiologically specific,
Excludes mechanisms/mode of dying

5. Introduction Concept of UCoD not well appreciated by clinicians
Immediate cause of death (ICOD) better appreciated by clinicians
Why UCoD?
primary tabulation of national mortality data
international comparisons

6. Introduction
Death certificates are main source of cause of death information globally
The “cause of death” section of the death certificate is designed to point out:
Immediate cause of death
Sequence from the underlying cause of death to the immediate cause of death
Any other conditions not directly leading to death but contributing to death
Duration of the reported conditions.

7. Introduction
Death certificate layout

8. Introduction UCoD should be entered on the lowest used line of Part I
UCoD is selected and coded using ICD-10 (usually by non- clinicians)
Accurate and complete filling of death certificate by clinicians will facilitate the selection of the underlying cause of death.

9. Introduction
Routine mortality surveillance in KATH revealed common errors in death certificate completion.
To help provide feedback to clinicians to improve practice we set out to:
Document some errors of completion of death certificates likely to affect accurate selection of UCoD
Assess frequencies of these errors
Make recommendations towards improving accurate filling of death certificates

10. Methods 1/2
Study site: Komfo Anokye Teaching Hospital (1,300-bed tertiary facility)
A retrospective review of mortality surveillance data in (4583 deaths)
Excluded neonatal deaths (771)
Systematic sampling done to select 510 out of 3812 deaths
Data entered and analyzed with Epi Info 7
Four types of errors of DC completion pre-specified for analysis

11. Methods 2/2 Pre-specified errors of completion:
Sequencing error (illogical cause of death sequence)
Mechanism of death/non-specific causes of death without acceptable underlying cause of death
Two or more competing underlying causes listed
Underlying cause of death placed in Part II
Pre-specified errors were determined by 2 physicians and if no agreement, a third physician brought in.

12. Methods
Inaccurate completion of death certificates were assessed assuming accurate diagnosis by attending clinician.
Did not assess diagnostic accuracy of the cause of death by attending clinician.
Did not include death certificates from pathologists or coroner

13. Methods: Did not assess errors such as:
wrong/ non-standard abbreviations
time intervals not recorded (approximate interval between presumed onset and date of death for each condition listed in Part I)
Inadequate level of detail on condition

14. Results
344(67.5%) out of 510 deaths had death certificates completed by attending clinicians.
Out of 344, 56 (16.3%) had illogical cause-of-death causal sequence
53 (15.4 %) had mechanism of death/non-specific causes listed without an acceptable underlying cause of death,
16 (4.7 %) had two or more competing causes listed
37 (10.8 %) had underlying cause of death placed in part II of the death certificate.
In all, 126 ( 36.6%) had at least one of the 4 types of error

15. Results: Sequencing error
Example 1
I a) Hepatic encephalopathy
I b) lobar pneumonia
Example 2:
I a) Pulmonary Tuberculosis
I b) Cerebral toxoplasmosis

16. Results: Sequencing error
Example 3 I a) Extrapulmonary TB I b) Electrolyte imbalance Example 4 I a) Presumed stage 4 Retroviral Infection I b) Severe acute malnutrition

17. Results: Mechanism of death/non-specific causes
Example 1 I a) Cardiogenic shock I b) Heart failure Example 2: I a) Biventricular failure I a) Respiratory failure Example 3: I a) Multiple organ dysfunction syndrome

18. Results: Mechanism of death/Non-specific causes:
Example 4:
I a) Septic shock
Example 5:
I a) Acute-on-chronic kidney disease
I b) Uraemic encephalopathy

19. Results: Two or more competing causes
Example 1 I a) Diabetic nephropathy I b) Hypertension II. Status epilepticus, aspiration pneumonia Example 2 I a) Right hemispheric CVA with left hemiparesis I b) Systemic hypertension, Diabetes Mellitus

20. Results: Two or more competing causes
Example 3 I a) Newly diagnosed HIV infection I b) Chronic hepatitis B infection

21. Results: Underlying cause placed in Part II
Example 1
1a) Altered mental state with recurrent seizures
1b) Cerebral toxoplasmosis
II. Retroviral disease
Example 2
I a) Paralytic ileus
I b) Spontaneous bacterial peritonitis
II. Alcoholic liver cirrhosis

22. Results: Underlying cause placed in Part II
Example 3 I a) Respiratory arrest/Cardiac arrest I b) Severe Infection II Burns 96% (full thickness) Example 4 I a) Sepsis I b) Gangrene of left foot II. Type 2 Diabetes mellitus with nephropathy

23. Discussion
To get accurate mortality data from death certificates we need:
Diagnostic accuracy
UCoD and sequence of events from UCoD to immediate cause of death should be well completed on death certificate (with time intervals, no abbreviations)
Inclusion of WHO-recommended level of detail
No deliberate falsification of diagnoses/ omission of diagnoses
Selection of UCoD and coding (usually by non-clinician) should be accurate
Errors can occur at any level
This work focused on the second one only.

24. Discussion
The results indicated that at least 36% had one major error likely to affect accurate selection of UCoD.
Consistent with previous studies using similar categories of major errors ranging from 16% to 33%
Errors in sequencing (16.3%) and errors in reporting mechanisms of death/unspecific causes (15.4%) the most frequent errors
Consistent with previous studies in South Africa, Greece, Australia, Taiwan and Canada.
At variance with study in Nepal which had 2 or more competing causes as most frequent (ICU patients)

25. Discussion Various reasons found for these errors in other studies:
Several co-morbidities which can concurrently lead to death (especially in elderly patients)
Copying of the admission and discharge diagnoses directly onto the DC by clinician who did not attend to deceased
Difficulty in finding specific etiology in some conditions like sepsis
Poor knowledge of Death Certificate completion
Low perceived importance of the Death Certificate

26. Discussion
Educational interventions used in previous studies proved useful in improving DC accuracy
Use of printed materials on death certificate completion alone led to a led to significant drop in Kansas USA though not much improvement seen in similar intervention in Australia
Interactive sessions have been shown to perform much better.
Studies in Canada, UK and Kansas, USA showed that interactive workshops/seminars resulted in significant decrease in major errors .

27. Conclusion
At least 36% of death certificates assessed had errors likely to affect correct choice of UCOD.
Most frequent errors were sequencing errors and stating mechanism of death/ unspecific causes without acceptable UCOD

28. Recommendations
In KATH, we propose that during mortality meetings discussions be held on the correct completion of death certificates for the mortality cases discussed.

29. References
World Health Organization. International statistical classification of diseases and related health problems. - 10th revision, Volume 2 Instruction Manual, edition
 Slater DN. Certifying the cause of death: an audit of wording inaccuracies. J Clin Pathol 1993: 46(3):232-4
B Swift, K West. Death certification: an audit of practice entering the 21st Century. J Clin Pathol 2002;55:275–279.
Cheng T-J, Lee F-C, Lin S-J, et al. Improper cause-of-death statements by specialty of certifying physician: a cross-sectional study in two medical centres in Taiwan. BMJ Open 2012;2:e
Haque et al. Death certificate completion skills of hospital physicians in a developing country. BMC Health Services Research :205.
Myer KA, Farquhar DRE. Improving the accuracy of death certification. CMAJ 1998;158:1317e23.

30. References
Bobbi S. Pritt, Nicholas J. Hardin, Jeffrey A. Richmond, and Steven L. Shapiro (2005) Death Certification Errors at an Academic Institution. Archives of Pathology & Laboratory Medicine: November 2005, Vol. 129, No. 11, pp
Burger EH, van der Merwe L, Volmink J. Errors in the completion of death notification form. S Afr Med J 2007;97:1077e81.
Katsakiori PF, Panagiotopoulou EC, Sakellaropoulos GC, Papazafiropoulou A, Kardara M.  Errors in death certificates in a rural area of Greece. Rural and Remote Health (Internet) 2007; 7: Available: (Accessed 7 July 2016)
Maharjan L, Shah A, Shrestha KB et al. Errors in cause-of-death statement on death certificates in intensive care unit of Kathmandu, Nepal. BMC Health Services Research (2015) 15:507
Selinger CP, Ellis RA, Harrington MG. A good death certificate: improved performance by simple educational measures. Postgraduate Medical Journal. 2007;83(978): doi: /pgmj

31. Thank you.