Common certification issues
Common certification issues
The role of the ABS is to produce statistical outputs by applying ICD-10 codes to the conditions recorded on the Medical Certificate of Cause of Death. The ABS utilises ICD-10 coding rules to assign an underlying cause of death. The following sections outline common issues with death certification which can make application of ICD-10 codes and coding rules difficult including:
- Cancer and neoplasms
- Dementia
- Infectious diseases
- Acute respiratory infections including COVID-19, Influenza and Respiratory Syncytial virus
- External causes
- Fractures
- Skin conditions
- Rare conditions
- Pulmonary embolism
- Renal failure
Cancer and neoplasms
Certification of cancer and neoplasms
Neoplasms are classified by site, behaviour and morphology. This information is used to assign the appropriate ICD code to the neoplasm. Insufficient information can lead to the incorrect assignment of a term. For example, terms such as 'neoplasm', 'mass,' 'growth' and 'tumour' should not be used without qualification as to whether malignant or benign.
Common issues with certification of neoplasms include:
- Not stating the site of the neoplasm.
- Not stating the behaviour of the neoplasm. For example, sometimes a term such as 'brain tumour' is used interchangeably with 'brain cancer'. If a brain cancer such as a frontoparietal glioblastoma is described as a 'brain tumour' it will be assigned as a benign tumour rather than a malignancy.
- Lack of clarity of whether the cancer is primary or secondary. The term 'metastatic lung cancer' may mean that the cancer has metastasised from the lung or it may mean that it has metastasised to the lung. It is important to clarify if a cancer is primary or secondary.
- The use of broad terms to describe multiple sites resulting in poor specificity such as 'bowel cancer', 'head and neck cancer', or 'oral cancer'. Further specificity is required to identify the exact site.
The following guidelines should be followed:
| Term | Specificity required |
|---|---|
| Behaviour | Malignant, benign, in situ, unknown behaviour. If malignant: clearly define if cancer is primary or secondary. |
| Site | Always state the exact site if known (do not use broad terms to encompass a site). |
| Morphology | If known, specify histological classification of the tissue. |
The following terms should not be used:
| Do not use terms in this column | Use instead |
|---|---|
| Head and neck cancer | Specify precisely if skin surface or other site e.g. skin of lip, skin of eyelid, skin of ear, skin of scalp, skin of neck, inner cheek, base of tongue, dorsal surface of tongue, gum, salivary gland, nasopharynx, hypopharynx, pyriform sinus, etc. |
| Bowel cancer | Specify exact site e.g. colon cancer, sigmoid colon cancer, cancer of rectosigmoid junction, etc. |
| Abdominal cancer | Specify exact site e.g. body of stomach, gastro-oesophageal junction, pylorus, etc. |
| Squamous cell carcinoma | Specify precisely if skin surface or other site e.g. squamous cell carcinoma of lung, squamous cell carcinoma of skin of face, squamous cell carcinoma skin of lip, etc. |
| Neuroendocrine cancer | Specify site e.g. neuroendocrine carcinoma of lung, etc. |
| Melanoma | Specify site e.g melanoma of eye (orbit, ocular, etc), vulvar melanoma, scrotal melanoma, etc. |
| Transitional cell carcinoma | Specify site e.g. transitional cell carcinoma of kidney, transitional cell carcinoma of bladder, transitional cell carcinoma of ureter, etc. |
Certifying primary cancers
- The primary site should always be indicated, even though the primary growth may have been removed long before death. If a secondary growth is included in the sequence of events leading to death, record the site of the secondary growth due to the site of the primary growth.
- If the primary site is unknown, this must be stated on the certificate.
- Avoid using broad terms set out in the table above.
- Add as much specification as possible to the site as set out in the table below.
- Clearly differentiate between primary and secondary cancers on the certificate.
- If there are multiple primary sites, certify all sites individually. Do not use 'multiple primaries'.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Secondary liver adenocarcinoma. Approximate interval between onset and death: 1 year
- Part 1(b): Resected primary adenocarcinoma of the lower lobe of lung. Approximate interval between onset and death: 3 years
- Parts 1(c), 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Long term cigarette smoking, alcohol abuse. Approximate interval between onset and death: 40 years, 20 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Secondary liver adenocarcinoma. Approximate interval between onset and death: 1 year
- Part 1(b): Primary cancer unknown. Approximate interval between onset and death: 3 years
- Parts 1(c), 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Anaemia, recurrent urinary tract infection, chronic kidney disease. Approximate interval between onset and death: 12 months, 12 months, 5 years
Specificity of neoplasm sites
To provide the details for identification of the underlying cause of death, the primary neoplasm sites listed in the table below require at least one of the qualifying terms (where specificity is available). Certifiers should be as specific as possible when certifying the site of any neoplasm, not just those sites listed below.
The four examples after the table show how deaths due to cancer may be certified. In the examples, the site of the cancer is clearly specified as well as whether the cancer is primary or secondary.
| Site | Subsite to be specified where applicable | Examples of subtype or other qualifying terms to be used where applicable |
|---|---|---|
| Lip | Lower, upper, commissure, skin of lip, overlapping | Squamous cell carcinoma |
| Mouth | Cheek (mucosa), vestibule, retro molar, overlapping | Squamous cell carcinoma |
| Pharynx | Nasopharynx, hypopharynx, oropharynx, tonsil, pyriform sinus, overlapping | Squamous cell carcinoma |
| Oral | Tongue, salivary gland, palate, gum, overlapping | Squamous cell carcinoma |
| Skin | Vulva, vagina, penis, scrotum, other specified site | Melanoma (by site), basal cell carcinoma (by site), squamous cell carcinoma (by site) |
| Liver | Hepatocellular, intrahepatic duct | Sarcoma, angiosarcoma, hepatoblastoma |
| Bowel | Large (colon), small, colon with rectum, sigmoid colon | |
| Uterus | Cervix uteri, corpus uteri, ligament, overlapping | |
| Endocrine gland | Parathyroid, pituitary, craniopharyngeal, pineal, aortic body, pluriglandular | |
| Adrenal gland | Medulla, cortex | |
| Respiratory | Nasal cavity, middle ear, accessory sinus, mediastinum, trachea, thymus, bronchus, larynx, overlapping | |
| Lung | Upper lobe, lower lobe, middle lobe, main bronchus, overlapping | Primary, secondary |
| Breast | Upper inner quadrant, lower inner quadrant, upper outer quadrant, axillary tail, central portion, nipple and areola, overlapping | |
| Urinary organs | Kidney, ureter, bladder, urethra, paraurethral gland, overlapping | |
| Central nervous system | Meninges, brain, 'specific' ventricle, brain stem, cranial nerve, spinal cord, cauda equina, overlapping, | Primary, secondary |
| Gastrointestinal system | Cervical part of oesophagus, thoracic part of oesophagus, abdominal part of oesophagus, gastro-oesophageal junction, fundus of stomach, body of stomach, pyloric antrum, pylorus, duodenum, jejunum, ileum, Meckel diverticulum, caecum, appendix, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, anal canal |
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Example of a completed Medical Certificate of Cause of Death. The certificate is filled out as follows:
- Part 1(a): Aspiration pneumonia. Approximate interval between onset and death: 1 week
- Part 1(b): Dysphagia. Approximate interval between onset and death: 3 weeks
- Part 1(c): Primary oesophageal carcinoma. Approximate interval between onset and death: 6 months
- Parts 1(d) and 1(e) Blank. Approximate interval between onset and death: Blank
- Part 2: Smoking, chronic alcohol abuse, malnutrition. Approximate interval between onset and death: 30 years, 20 years, 5 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Aspiration pneumonia. Approximate interval between onset and death: 5 days
- Part 1(b): Dysphagia. Approximate interval between onset and death: 6 months
- Part 1(c): Primary squamous cell carcinoma of base of tongue. Approximate interval between onset and death: 6 months
- Parts 1(d) and 1(e) Blank. Approximate interval between onset and death: Blank
- Part 2: Cigarette smoking. Approximate interval between onset and death: 30 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Pulmonary embolism. Approximate interval between onset and death: 1 day
- Part 1(b): Secondary adenocarcinoma of peritoneum. Approximate interval between onset and death: 5 months
- Part 1(c): Primary adenocarcinoma of descending colon. Approximate interval between onset and death: 9 months
- Parts 1(d) and 1(e) Blank. Approximate interval between onset and death: Blank
- Part 2: Poor diet, obesity, smoking. Approximate interval between onset and death: 50 years, 50 years, 50 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Respiratory failure. Approximate interval between onset and death: 2 hours
- Part 1(b): Secondary metastatic lung cancer. Approximate interval between onset and death: 1 month
- Part 1(c): Primary gastroesophageal junction cancer. Approximate interval between onset and death: 12 months
- Parts 1(d), 1(e) and Part 2: Blank. Approximate interval between onset and death: Blank
Dementia
Certification of dementia
When certifying deaths due to dementia:
- If the type or cause of dementia is known this must be specified on the death certificate e.g. Alzheimer’s disease, vascular dementia, frontotemporal dementia, Lewy body dementia, dementia due to alcohol abuse.
- If the type or cause of dementia is unknown document this as 'unspecified dementia'.
Mixed dementia
If two or more types of dementia have contributed to the death, ensure both are specified on the death certificate. The following two examples show how mixed dementia may be certified.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Aspiration pneumonia. Approximate interval between onset and death: 5 days
- Part 1(b): Alzheimer’s and vascular dementia. Approximate interval between onset and death: 6 years
- Parts 1(c), 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Bedbound, recurrent infections from pressure sores. Approximate interval between onset and death: 4 months, 4 months
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Staphylococcus aureus urosepsis. Approximate interval between onset and death: 1 day
- Part 1(b): Urinary tract infection from indwelling catheter. Approximate interval between onset and death: 2 weeks
- Part 1(b): Urinary retention. Approximate interval between onset and death: 2 months
- Part 1(d): Mixed dementia: Alzheimer’s and Lewy body dementia. Approximate interval between onset and death: 10 years
- Part 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Delirium. Approximate interval between onset and death: 7 days
Infectious diseases
Certification of infectious or parasitic diseases
When certifying deaths due to infectious or parasitic diseases:
- Identify whether a primary infection was bacterial, viral or fungal.
- State the name of the causative agent, if the disease name does not imply this.
- Provide the site of the infection (e.g. urinary tract, respiratory tract).
- Specify the organism on the MCCD if it is known.
Sepsis and septicaemia
Where sepsis and septicaemia is the direct cause of death, certifiers should document:
- The site of the original infection.
- The causative organism.
The following example shows how more specificity can be applied to sepsis. These principles can be applied to other infections.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Septic shock. Approximate interval between onset and death: 1 day
- Part 1(b): Staphylococcus aureus infection. Approximate interval between onset and death: 1 week
- Part 1(c): Lower limb cellulitis. Approximate interval between onset and death: 3 weeks
- Parts 1(d) and 1(e) Blank. Approximate interval between onset and death: Blank
- Part 2: Type 2 diabetes mellitus. Approximate interval between onset and death: 30 years
Pneumonia and bronchopneumonia
For deaths due to pneumonia or bronchopneumonia, identify:
- If the condition is viral, bacterial, fungal, primary hypostatic or due to aspiration.
- The causative organism where it is known.
- Any underlying condition that may have led to the pneumonia.
- Any condition leading to inactivity or debility, if this was the cause of the pneumonia.
The following example shows how more specifity can be added to pneumonia on the MCCD.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Klebsiella pneumoniae hypostatic pneumonia. Approximate interval between onset and death: 1 day
- Part 1(b): Inactivity. Approximate interval between onset and death: 1 week
- Part 1(c): Cerebral infarction with hemiplegia. Approximate interval between onset and death: 3 weeks
- Part 1(d): Cerebrovascular arteriosclerosis. Approximate interval between onset and death: 20 years
- Parts 1(e) and Part 2: Blank. Approximate interval between onset and death: Blank
Acute respiratory infections including COVID-19, Influenza and Respiratory Syncytial virus
Terminology
Viral illnesses should be recorded on the Medical Certificate of Cause of Death (MCCD) where the disease caused, or is clinically diagnosed as having caused, or contributed to death. Viral illnesses should be recorded in Part 1 where it was a part of the chain of events leading to death. Viral illnesses should be recorded in Part 2 where they are thought to have contributed to the death but was not part of the direct chain of events leading to death.
COVID-19:
- Do not use the term coronavirus. Instead state that is was COVID-19, SARS-CoV-2, etc.
- Specify whether the infection is current or a sequelae complication (e.g. long COVID-19).
Influenza:
- State the strain if known (e.g. Influenza A, B or H1N1).
The following example demonstrates how a death due to a viral illness may be certified. The strain is clearly specified, as are complications of the virus.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Respiratory failure. Approximate interval between onset and death: 1 day
- Part 1(b): Viral pneumonia. Approximate interval between onset and death: 5 days
- Part 1(c): Influenza A. Approximate interval between onset and death: 10 days
- Parts 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Prostate adenocarcinoma, past myocardial infarction, atrial fibrillation. Approximate interval between onset and death: 5 years, 3 years, 3 years
Complications of viral illnesses leading to death
Specification of the causal pathway leading to death in Part 1 of the certificate is important and all conditions and symptoms should be included. For example, in cases where COVID-19 causes pneumonia and fatal respiratory distress, both pneumonia and respiratory distress should be included along with COVID-19 in Part 1. The duration of each disease and symptom should also be included. Certifiers should include as much detail as possible based on their knowledge of the case, medical records, laboratory testing, etc.
The following two examples show how complications of a viral illness can be certified.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Acute respiratory distress syndrome. Approximate interval between onset and death: 2 days
- Part 1(b): Respiratory syncytial virus pneumonitis . Approximate interval between onset and death: 2 weeks
- Parts 1(c) 1(d), 1(e) and Part 2: Blank. Approximate interval between onset and death: Blank
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Acute respiratory distress syndrome. Approximate interval between onset and death: 2 days
- Part 1(b): COVID-19 pneumonia. Approximate interval between onset and death: 10 days
- Part 1(c): COVID-19. Approximate interval between onset and death: 12 days
- Parts 1(d), 1(e) and Part 2: Blank. Approximate interval between onset and death: Blank
Viral illnesses with co-morbidities
Existing conditions, especially those which are chronic in nature, may have also contributed to death and should be certified in Part 2 of the MCCD. Chronic conditions may include but are not limited to coronary artery disease, chronic obstructive pulmonary disease, diabetes, cancer or disabilities.
The following three examples show how comorbidities may be certified on the MCCD for deaths due to acute respiratory illnesses.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Acute respiratory distress syndrome. Approximate interval between onset and death: 2 days
- Part 1(b): COVID-19 pneumonia. Approximate interval between onset and death: 10 days
- Part 1(c): COVID-19. Approximate interval between onset and death: 12 days
- Parts 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Coronary artery disease, type 2 diabetes, chronic obstructive pulmonary disease, hypertension. Approximate interval between onset and death: 10 years, 20 years, 10 years, 10 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Acute respiratory distress syndrome. Approximate interval between onset and death: 2 days
- Part 1(b): Acute pulmonary fibrosis. Approximate interval between onset and death: 10 days
- Part 1(c): COVID-19. Approximate interval between onset and death: 12 days
- Parts 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Diffuse large B cell lymphoma, immunosuppressant therapy. Approximate interval between onset and death: 5 years, 5 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Acute respiratory distress syndrome. Approximate interval between onset and death: 2 days
- Part 1(b): Pneumonia. Approximate interval between onset and death: 10 days
- Part 1(c): Respiratory syncytial virus. Approximate interval between onset and death: 12 days
- Parts 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Cerebral palsy. Approximate interval between onset and death: 80 years
Long COVID-19
If a past COVID-19 infection caused lasting complications which lead to death, the original infection should be certified on the MCCD. This is demonstrated in the following example.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Respiratory failure. Approximate interval between onset and death: 2 days
- Part 1(b): Lung fibrosis. Approximate interval between onset and death: 2 weeks
- Part 1(c): Long COVID-19. Approximate interval between onset and death: 6 months
- Parts 1(d), 1(e) and part 2: Blank. Approximate interval between onset and death: Blank
Acute respiratory infections as contributing causes of death
Acute respiratory infections should be recorded as a contributing cause of death where an individual is positive for a viral illness but there is a disease or injury pathway to death that is not directly caused by the virus. For example, a person may have late stage cancer that has metastasised extensively causing organ damage leading to death. This person may also have contracted COVID-19. While the virus or its complications may have negatively impacted health in an immuno-compromised person, the virus itself did not cause the terminal event leading to death (e.g. organ failure caused by metastases). In this circumstance, the viral illness should be certified in Part 2.
Incidental viral infections which did not contribute to the death should not be certified on the MCCD.
The following two examples show how an acute respiratory illness can be certified in Part 2 of the MCCD.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Multiple organ failure. Approximate interval between onset and death: 2 days
- Part 1(b): Bone and liver metastases. Approximate interval between onset and death: 2 months
- Part 1(c): Invasive ductal carcinoma of right breast. Approximate interval between onset and death: 4 years
- Parts 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: COVID-19, chemotherapy-induced thrombocytopenia, type 2 diabetes, coronary artery disease. Approximate interval between onset and death: 4 days, 2 months, 20 years, 10 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Traumatic subdural haemorrhage. Approximate interval between onset and death: 2 hours
- Part 1(b): Fall from bed with headstrike. Approximate interval between onset and death: 2 hours
- Parts 1(c), 1(d) and 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: COVID-19, frailty, bedbound, Alzheimer’s disease. Approximate interval between onset and death: 7 days, 4 weeks, 4 weeks, 15 years
External causes
Injuries
Injuries should never be reported on the Medical Certificate of Cause of Death (MCCD) without the circumstances that led to the injury. In most instances, deaths occurring as the result of an accident must by law be referred to the coroner. When a medical practitioner has occasion to issue a MCCD relating to a death resulting from an accident, the circumstances of the accident as well as the injuries incurred need to be reported. For example, 'fractured skull with cerebral haemorrhage due to accidental fall on stairs at home' or 'fractured neck of femur due to fall from bed in nursing home'.
When certifying deaths due to external causes:
- Include all injuries sustained and avoid using non-specific terms such as 'multiple injuries'.
- If a death is due to late effects of a previous injury, state the circumstances of this injury, e.g. bronchopneumonia due to paraplegia due to motor vehicle accident 3 years ago.
- Always certify the reason for the injury (the mechanism of death).
- Check guidelines for referring a death to the coroner as most deaths due to external causes are reportable deaths in Australia.
The following example shows how a death due to an external cause may be certified. The manner (accident) and mechanism (trip on carpet) are clearly stated, as well as the resulting injury and associated complications. Risk factors which increased the propensity to fall and severity of the injury are also included in Part 2 of the certificate.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Klebsiella pneumonia. Approximate interval between onset and death: 2 days
- Part 1(b): Internal fixation for fracture repair. Approximate interval between onset and death: 3 weeks
- Part 1(c): Traumatic neck of femur fracture. Approximate interval between onset and death: 3 weeks
- Part 1(d): Trip on carpet edge at home. Approximate interval between onset and death: 3 weeks
- Part 1(e): Blank
- Part 2: Frailty, osteoporosis, macular degeneration, osteoarthritis. Approximate interval between onset and death: 3 years, 20 years, 10 years, 10 years
Fractures
Certification of fractures
When certifying deaths due to fractures and other conditions for which the cause can be either traumatic or pathological, specify the nature and cause of the fracture. For traumatic fractures specify the mechanism or the cause of the injury (e.g. motor vehicle crash, fall down stairs) and the manner or intent of the injury (e.g. unintentional). For pathological fractures specify the disease or condition which resulted in the fracture (e.g. malignancy, osteoporosis).
The following example provides an example of how a traumatic fracture may be certified. The cause of the fracture is clearly certified with the manner and mechanism indicating that it is a death due to trauma.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Post-operative pneumonia. Approximate interval between onset and death: 2 days
- Part 1(b): Internal fixation for fracture repair. Approximate interval between onset and death: 3 weeks
- Part 1(c): Neck of femur fracture. Approximate interval between onset and death: 3 weeks
- Part 1(d): Unintentional fall down stairs at home. Approximate interval between onset and death: 3 weeks
- Part 1(e): Blank. Approximate interval between onset and death: Blank
- Part 2: Frailty. Approximate interval between onset and death: 3 years
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Aspiration pneumonia. Approximate interval between onset and death: 2 days
- Part 1(b): Metastatic mediastinal malignancy with pathological rib fractures. Approximate interval between onset and death: 14 days
- Part 1(c): Primary small cell lung cancer of right lower lobe. Approximate interval between onset and death: 2 years
- Parts 1(d), 1(e) and 2: Blank. Approximate interval between onset and death: Blank
Skin conditions
Certification of skin conditions
When certifying conditions of the skin such as wounds, ulcers and haemorrhages specify whether the condition is traumatic or atraumatic. Specify the site, cause and any risk factors of the skin condition such as immobility, diabetes or vascular disease. Where applicable, specify if an infection is present and give the name of the causative organism where known. The following example demonstrates how a skin condition may be certified.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Septic shock. Approximate interval between onset and death: 1 day
- Part 1(b): Staphylococcus aureus sepsis. Approximate interval between onset and death: 1 week
- Part 1(c): Chronic atraumatic lower leg wounds. Approximate interval between onset and death: 2 months
- Part 1(d): Peripheral vascular disease. Approximate interval between onset and death: 10 years
- Part 1(e): Type 2 diabetes mellitus. Approximate interval between onset and death: 20 years
- Part 2: Coronary artery disease, obesity. Approximate interval between onset and death: 10 years, 20 years
Rare conditions
Certification of rare conditions
It is accepted that on occasion a medical practitioner will have responsibility for certifying a death that is considered a rare occurrence in Australia. To ensure high quality data, the ABS reviews all records that are considered to be of a rare or improbable nature in Australia. To assist this process, it is important that when certifying deaths of this nature that additional information be provided on the certificate to confirm that condition has been proven histologically or through other extensive medical testing. As an example, if the disease that caused death is Creutzfeldt-Jakob Disease, then the addition of the term 'histologically proven' will ensure accurate code assignment. The list below, whilst not exhaustive, provides examples of the types of conditions that are considered to be rare or impossible in Australia.
- Acute poliomyelitis
- Anthrax
- Botulism
- Creutzfeldt-Jakob Disease
- Diphtheria
- Q fever
- Rabies
- Smallpox
- Typhoid fever
- Yellow fever
The following example shows how a death due to a rare disease may be certified.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line. The certificate is filled out as follows:
- Part 1(a): Multiorgan failure. Approximate interval between onset and death: 2 days
- Part 1(b): Bacterial infection. Approximate interval between onset and death: 7 days
- Part 1(c): Immobility. Approximate interval between onset and death: 6 weeks
- Part 1(d): Dementia. Approximate interval between onset and death: 2 months
- Part 1(e): Creutzfeldt-Jakob disease, histologically confirmed. Approximate interval between onset and death: 4 months
- Part 2: Blank. Approximate interval between onset and death: Blank
Pulmonary embolism
Certification of pulmonary embolism
It is rare for a pulmonary embolism to occur spontaneously in anyone below 75 years of age and there are a large variety of underlying causes of this condition. Where pulmonary embolism is the direct cause or mode of death it should be entered as such in Line 1(a) of the death certificate, with its underlying cause(s) sequenced in the ‘due to’ relationship on the lines below it. This is demonstrated in the following example.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): Pulmonary embolism. Approximate interval between onset and death: 2 hours
- Part 1(b): Deep vein thrombosis. Approximate interval between onset and death: 2 weeks
- Part 1(c): Morbid obesity. Approximate interval between onset and death: 40 years
- Part 1(d): Blank. Approximate interval between onset and death: Blank
- Part 2: Obstructive sleep apnoea, osteoarthritis. Approximate interval between onset and death: 30 years, 20 years
Renal failure
Certification of renal failure
Where renal failure is entered on the Medical Certificate of Cause of Death, identify:
- If the renal failure was acute, chronic or end-stage. If known, put the stage of kidney disease (e.g. chronic kidney disease stage 4).
- The cause of the renal failure if known.
The following example shows how renal failure may be certified on the MCCD. The cause of the renal failure is clearly certified.
Example of a completed Medical Certificate of Cause of Death. The certificate contains 6 lines for completion separated into two parts. Part 1, line A for the disease or condition leading directly to death. Part 1 lines B, C, D and E for antecedent causes which are morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. Part 2 of the certificate is a single line for other significant conditions contributing to the death but not directly related to the disease or condition causing it. For both Part 1 and Part 2 there is a column to record the approximate interval between onset and death for the conditions on each line.
The certificate is filled out as follows:
- Part 1(a): End stage renal failure. Approximate interval between onset and death: 1 week
- Part 1(b): Focal glomerular sclerosis. Approximate interval between onset and death: 2 years
- Part 1(c): Type 1 diabetes mellitus. Approximate interval between onset and death: 70 years
- Part 1(d): Blank. Approximate interval between onset and death: Blank
- Part 2: Cigarette smoking. Approximate interval between onset and death: 40 years