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Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage:

Death certificate errors in one Saudi Arabian


Khaldoon Aljerian

To cite this article: Khaldoon Aljerian (2018): Death certificate errors in one Saudi Arabian
hospital, Death Studies, DOI: 10.1080/07481187.2018.1461712

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Accepted author version posted online: 14

May 2018.
Published online: 20 Sep 2018.

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Death certificate errors in one Saudi Arabian hospital

Khaldoon Aljerian
Forensic Medicine Unit, Department of Pathology, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia

Proper completion of death certificates is of vital importance. This study assessed the accur-
acy of death certification at one major hospital in Riyadh, Saudi Arabia. We collected all cer-
tificates from 1997 to 2016 and scored them on the degree of accuracy. We found no errors
of incompleteness or missed contributors to death. However, in all certificates (100%), cause
of death was either incorrect or absent; 75% provided no cause of death. Further large-scale
studies should be conducted in other hospitals to determine the exact prevalence of these
serious errors.

Introduction certificates mainly by demonstrating its absence.

Indeed, death certification errors are a universal prob-
A death certificate is a legal document, filled out by an
lem; reported major error rates in a study at a univer-
attending physician or a coroner, that details an individ-
sity-affiliated medical center in the United States
ual’s personal information and cause of death (Kircher
ranged from 24% to 37% (Pritt, Hardin, Richmond, &
& Anderson, 1987; Ravakhah, 2006). Unlike many other
Shapiro, 2005). Error rates vary from 56% in the
records a physician or hospital may be required to com-
United Kingdom in 2012 (Fernando, Oxley, &
plete, a death certificate is publicly accessible and legally
Nottingham, 2012), to 89% among pediatric deaths in
required—issued for use in governmental practices
India (Gupta, Bharti, Singhi, Kumar, & Thakur, 2014).
(national statistics and assessments), legal proceedings In another example, including diabetes as a cause
(inheritances, insurance claims, etc.) and as closure for (or condition leading to) death for three countries was
family and friends, serving as the last record of the life inconsistent, leading to misrepresentation of national
of the deceased (BinSaeed et al., 2008; Haque, Shamim, statistics (Lu, Walker, Johansson, & Huang, 2005).
Siddiqui, Irfan, & Khan, 2013; Randall, 2014). Death Many other studies have shown how inconsistencies,
certificates consist of patient information (e.g., name, discrepancies, or lack of correct information has led to
date and time of death, cause and manner of death, and complications or erroneous conclusions (Goldman
contributing factors; Pritt, Hardin, Richmond, & et al. 1983; Govindan, Shapiro, Langa, & Iwashyna,
Shapiro, 2005), as well as epidemiological data essential 2014; Hempstead, 2009; Minelli & Marchetti, 2013).
for allocating resources for research and health pro- The correct completion of a death certificate is inte-
grams. Because hospital statistics, national morbidity gral to its validity as a legal and statistical document for
and mortality statistics, and data on disease prevalence government agencies (Fox et al., 2005; Klatt & Noguchi,
are derived from death certificates, they must be com- 1988; Papadakis et al., 2009; Saito, 2004). For this rea-
pleted fully and accurately (Pandya, Bose, Shah, son, the World Health Organization (WHO) developed
Chaudhury, & Phatak, 2009). Death certificates are guidelines and standardized instructions for their
sensitive and important documents; accuracy and proper completion (1994).
standardization are paramount for their validity. Continuous and detailed analysis of death certifica-
The published literature has emphasized the need tion accuracy is needed for a wide range of purposes
for comprehensive and accurate completion of death and should be undertaken regularly and diligently.

CONTACT Khaldoon Aljerian College of Medicine, Department of Pathology, Forensic Medicine Unit, King Saud
University, Riyadh 12372, Saudi Arabia.
The author meets the three authorship criteria of the International Committee of Medical Journal Editors: “Contributed substantially to conception and
design, or acquisition of data, or analysis and interpretation of data AND Drafted the article or revised it critically for important intellectual content AND
Gave final approval of the version to be published.”
This manuscript has not been published in any other journal, and it has not been submitted simultaneously for publication elsewhere.
ß 2018 Taylor & Francis Group, LLC

Saudi Arabia has encouraged its hospitals and medical Table 1. Grading of errors in death certificate completion.
centers to investigate the accuracy of death certifica- 0 No error
IAIncomplete (1 boxes not checked, time frame not completed, address or
tion across the country. The present study, conducted printed name of physician missing, or any other section on the form, such
at one large university hospital, aimed at assessing the as age and date of birth and death)
IBUse of abbreviations or illegible writing
accuracy of the completion and accuracy of death cer- ICDiagnoses not listed in a logical order
tification among its physicians, with the overall goals II Missed comorbidities contributing to death; known clinical diagnosis not
of improving accuracy and adding information to completely specified
IIIMissing or misclassified cause of death
national databases that may be of use for subse- IVWrong cause or manner of death
quent research. Reprinted from Pritt BS, Hardin NJ, Richmond JA, and Shapiro SL. “Death
Certification Errors at an Academic Institution.” (Arch Pathol Lab Med.
2005;129(11):1476–1479) with permission from Archives of Pathology &
Laboratory Medicine. Copyright 2005 College of American Pathologists.
This study was a retrospective audit conducted at
 All errors and types of errors (e.g., manner of
King Khalid University Hospital in Riyadh, Saudi
death listed as the cause, no cause of death listed at
Arabia, from January 1 to January 31, 2017. I obtained
all) were clearly identifiable from a simple review
permission to conduct this study from the hospital’s
of each certificate.
ethics review board. I collected all paper death certifi-
To ensure lack of bias, two pathologists randomly
cates filed in the mortuary records and dated between
reviewed 20 of the selected death certificates and
1997 and 2016. I included all records that met the fol-
recorded their findings. We agreed on each category.
lowing criteria: death occurred at King Khalid
University Hospital following admission for at least
48 hr; and death certification was confirmed and Results
signed by an attending physician, demonstrated by the
I retrieved 1729 death certificates from the hospital
presence of a signature and a staff number on
records, but excluded 41 because they were earlier
the record.
than 2 days, for a total of 1688 death certificates that
I scored the certificates based on their degree of
met the inclusion criteria. The deceased persons were
accuracy and the errors they contained, if any (legibil-
ity; completion of required fields; degree of detail of mostly men (66.4%). Mean age was 62 years (range
cause of death and relevant co-morbidities; inaccurate 14–114, SD ¼ 20.89).
or incorrect cause of death named). I identified no category I or II errors in the reports.
I assessed all death certificates independently, iden- I identified category III errors in 75% (1266) of the
tifying the number and type(s) of errors based on the reports: only 25% (424) listed the conditions that may
WHO guidelines for death certificate completion have led to death, and of these, only 30 (2%) correctly
(WHO, 1994) and on a scale developed for grading listed the conditions in the appropriate row or col-
errors in death certificates (Pritt, Hardin, Richmond, umn. Correct cancer-related causes of death included
& Shapiro, 2005). colon, prostate, breast, and liver cancer, but detail was
Errors were assigned a grade of 0 to IV (higher often lacking (histology type, locality). Errors in can-
grade means more severe; Table 1). A grade of 0 indi- cer-related causes of death included nonspecific label-
cated that no errors were found. Minor errors (grade ling such as “cancer,” “tumor,” “metastatic tumor,”
Ia–c and grade II) could include the following: “brain tumor,” or “colon tumor.” Correct non-cancer-
related causes of death included diabetic ketoacidosis,
 Grade Ia: incompleteness, for example, 1 boxes pneumonia, meningitis, gastrointestinal hemorrhage
not checked, time frame not completed, address or and perforation, or traffic accident, but records lacked
printed name of physician missing, or any other essential details such as the causative organism or
section on the form, such as age and date of birth complications leading to death.
and death), I found category IV errors (wrong cause or manner
 Grade Ib: abbreviation/illegible writing of death) in all (100%) records, meaning that an
 Grade Ic: diagnoses not listed in a logical order incorrect cause of death was listed, or cause of death
 Grade II: missed minor comorbidities was absent. Of these, 1186 (70%) listed
 Grade III errors are serious errors with missing or “cardiopulmonary arrest” as the cause of death; the
misclassified cause of death. rest listed comorbidities or mechanisms—such as
 Grade IV errors are serious errors with incorrect chronic ischemic heart disease, myocardial infarction,
cause or manner of death malignancy, renal failure, diabetes and even “traffic

accident”—rather than the specific cause. Similarly, or series of events constitute the chain leading to a
4% listed different types of organ failure (e.g., heart, patient’s death; high-pressure work and time con-
kidney, liver, and multiorgan), but these were mecha- straints; or that the wording or construction of the
nisms of death, rather than causes. Diabetes was listed death certificate makes it unclear what should be
as a cause in 2% of records without clearly stating a entered (Pritt, Hardin, Richmond, & Shapiro, 2005).
complication causing death. “Traffic accident” lacked Further research is needed to determine which of
the detail of the sequence of events leading to death these factors or combination of factors best explains
and suggested a manner of death that may not have the high rate of category III errors (missing or mis-
been a cause (e.g., not all traffic collisions are acci- classified cause of death) found in this study
dents, and traffic or transportation injuries may occur All studied records had category IV errors (wrong
in cars, on motorbikes or bicycles, to drivers, passen- cause or manner of death). These were errors in iden-
gers, or pedestrians). tifying the cause of death or in using a generic term
such as “cardiopulmonary arrest,” a practice that is
unacceptable according to the WHO (1994), because it
is more a mechanism of death and not a cause. This
In the records we evaluated for the present study, all finding needs to be taken seriously by issuing institu-
mandatory sections had been completed (we found no tions and the government bodies that supervise them.
abbreviations or shorthand), no diagnoses not listed in If all certificates incorrectly list cause of death, legal
a logical order, and no missed comorbidities contribu- proceedings (insurance, compensation) and national
ting to death; known clinical diagnosis not completely statistics on epidemiology and quality of life will be
specified (i.e., no category I or II errors); this was based on incorrect information and could lead to
similar to Pandya, Bose, Shah, Chaudhury, and Phatak errors in resource allocation (Pandya, Bose, Shah,
(2009). We expected to find no category I errors, Chaudhury, & Phatak 2009; Russell & Conroy, 1991).
because no death certificate can be submitted at King Other studies have found substantial error rates
Khalid University Hospital if the mandatory sections relating to recorded cause of death. In an audit of
are incomplete. If any such errors had been identified, practice, 55% of death certificates had been com-
the responsibility for addressing them would lie pleted to minimum standards, and many were miss-
equally with the physician who completed the certifi- ing information (Swift & West 2002). Similar to the
cate and the hospital administration. The finding of a findings of the present study, at a teaching hospital
lack of abbreviations or illegible shorthand was a posi- in India, 78.1% of death certificates contained errors
tive result; it is easy for physicians, who come into related to cause of death (Pandya, Bose, Shah,
repeated contact with the same diseases and condi- Chaudhury, & Phatak 2009). Additionally, death cer-
tions, to abbreviate names and symptoms uncon- tification errors were identified in 82% of death cer-
sciously (Parvaiz, Subramanian, & Kendall, 2008; tificates (category I, II, III, and IV errors in 72%,
Sinha, McDermott, Sriniva, & Houghton, 2011). 32%, 31%, and 17%, respectively) (Pritt, Hardin,
Hospital administration will reject any death certifi- Richmond, & Shapiro 2005). The fact that the death
cates that contain abbreviations because abbreviations certificates in the present study showed no category
may be misinterpreted (e.g., RTA could mean renal I or II errors may be explained by rigorous admin-
tubular acidosis or road traffic accident) or simply not istrative rules and feedback at King Khalid
understood. The fact that we did not find these types University Hospital. The higher rates of category III
of errors may indicate that physicians are aware of the and IV errors may have been due to perceived lack
drawbacks of abbreviation and are actively seek to of importance of the death certificate, or to lack of
counter it in important documentation. knowledgeable feedback. I suggest that the design of
Concerning category III errors (missing or misclas- the local death certificate is difficult to follow for
sified cause of death), most reports contained no valid physicians and completely lacks any instructions.
chain of events in the appropriate section. In most Additionally, there are no courses for death certifi-
cases, the records provided were a list of some or all cation at any teaching level. Furthermore, there
of an individual’s conditions, but did not establish a should be a committee that reviews death certificates
causal link or indicate relevance. This finding has sev- to guarantee quality.
eral possible explanations: that physicians do not The limitations of this study include that it is retro-
know how to correctly determine what comorbidities spective. Future studies designed to be prospective will

be of higher yield. Additionally, the study focused on autopsy in three medical eras. New England Journal of
one hospital. A multicenter approach will give a better Medicine, 308, 1000–1005.
Govindan, S., Shapiro, L., Langa, K. M., & Iwashyna, T. J.
idea of the death certification errors issue.
(2014). Death certificates underestimate infections as
Finding out how the level of error we found was proximal causes of death in the US. PLoS One, 9, e97714.
permissible over a 20-year period and pinpointing the Gupta, N., Bharti, B., Singhi, S., Kumar, P., & Thakur, J. S.
source of the problems needs to be a high priority. (2014). Errors in filling WHO death certificate in chil-
Future investigations should evaluate variables that dren: lessons from 1251 death certificates. Journal of
Tropical Pediatrics, 60, 74–78.
may impact error rates in death certificate reporting; Haque, A. S., Shamim, K., Siddiqui, N. H., Irfan, M., &
checks that are run on submitted reports; training of Khan, J. A. (2013). Death certificate completion skills of
physicians in certificate preparation and evaluation; hospital physicians in a developing country. BMC Health
and whether other institutions in Saudi Arabia have Services Research, 13, 205.
similar error rates. Hempstead, K. (2009). The accuracy of a death certificate
checkbox for diabetes: early results from New Jersey.
Public Health Reports, 124, 726–732.
Conclusion Kircher, T., & Anderson, R. E. (1987). Cause of death:
proper completion of the death certificate. JAMA, 258,
Proper completion of death certificates is vital for 349–352.
many legal and governmental practices at the national Klatt, E. C., & Noguchi, T. T. (1988). The medical examiner
and AIDS: death certification, safety procedures, and
level. This study found that although physicians com-
future medicolegal issues. American Journal of Forensic
pleted all necessary fields and actively countered the Medicine and Pathology, 9, 141–148.
use of abbreviations when filling out death certificates, Lu, T. H., Walker, S., Johansson, L. A., & Huang, C. N.
they often failed to correctly identify contributing (2005). An international comparison study indicated
comorbidities and events leading to death. All certifi- physicians’ habits in reporting diabetes in part I of death
certificate affected reported national diabetes mortality.
cates listed an incorrect cause of death, making them Journal of Clinical Epidemiology, 58, 1150–1157.
useless for government, legal, or even personal use. Minelli, N., & Marchetti, D. (2013). Discrepancies in death
Further large-scale studies should be conducted in certificates, public health registries, and judicial determi-
other hospitals, and the exact source of these nations in Italy. Journal of Forensic Sciences, 58, 705–710.
errors identified. Pandya, H., Bose, N., Shah, R., Chaudhury, N., & Phatak, A.
(2009). Educational intervention to improve death certifi-
cation at a teaching hospital. The National Medical
Journal of India, 22, 317–319.
Acknowledgements Papadakis, M., Sharma, S., Cox, S., Sheppard, M. N.,
Panoulas, V. F., & Behr, E. R. (2009). The magnitude of
The author would like to acknowledge the College of sudden cardiac death in the young: a death certificate-
Medicine, King Saud University (CMRC-College of medi- based review in England and Wales. Europace, 11,
cine research center) for their support. 1353–1358.
Parvaiz, M. A., Subramanian, A., & Kendall, N. S. (2008).
The use of abbreviations in medical records in a multidis-
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