Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: http://www.tandfonline.com/loi/udst20

Death certificate errors in one Saudi Arabian

hospital

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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DEATH STUDIES
https://doi.org/10.1080/07481187.2018.1461712

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

ABSTRACT
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.

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

CONTACT Khaldoon Aljerian khaldoonaljerian@gmail.com 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
2 K. ALJERIAN
Saudi Arabia has encouraged its hospitals and medical
centers to investigate the accuracy of death certifica-
tion across the country. The present study, conducted
at one large university hospital, aimed at assessing the
accuracy of the completion and accuracy of death cer-
tification among its physicians, with the overall goals
of improving accuracy and adding information to
national databases that may be of use for subse-
quent research.
Method
This study was a retrospective audit conducted at
King Khalid University Hospital in Riyadh, Saudi
Arabia, from January 1 to January 31, 2017. I obtained
permission to conduct this study from the hospital’s
ethics review board. I collected all paper death certifi-
cates filed in the mortuary records and dated between
1997 and 2016. I included all records that met the fol-
lowing criteria: death occurred at King Khalid
University Hospital following admission for at least
48 hr; and death certification was confirmed and
signed by an attending physician, demonstrated by the
presence of a signature and a staff number on
the record.
I scored the certificates based on their degree of
accuracy and the errors they contained, if any (legibil-
ity; completion of required fields; degree of detail of
cause of death and relevant co-morbidities; inaccurate
or incorrect cause of death named).
I assessed all death certificates independently, iden-
tifying the number and type(s) of errors based on the
WHO guidelines for death certificate completion
(WHO, 1994) and on a scale developed for grading
errors in death certificates (Pritt, Hardin, Richmond,
& Shapiro, 2005).
Errors were assigned a grade of 0 to IV (higher
grade means more severe; Table 1). A grade of 0 indi-
cated that no errors were found. Minor errors (grade
Ia–c and grade II) could include the following:

Grade Ia: incompleteness, for example, 1 boxes
not checked, time frame not completed, address or
printed name of physician missing, or any other
section on the form, such as age and date of birth
and death),

Grade Ib: abbreviation/illegible writing

Grade Ic: diagnoses not listed in a logical order

Grade II: missed minor comorbidities

Grade III errors are serious errors with missing or
misclassified cause of death.

Grade IV errors are serious errors with incorrect
cause or manner of death
Table 1. Grading of errors in death certificate completion.
0 No error
IAIncomplete (1 boxes not checked, time frame not completed, address or
printed name of physician missing, or any other section on the form, such
as age and date of birth and death)
IBUse of abbreviations or illegible writing
ICDiagnoses not listed in a logical order
II Missed comorbidities contributing to death; known clinical diagnosis not
completely specified
IIIMissing or misclassified cause of death
IVWrong cause or manner of death
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.

All errors and types of errors (e.g., manner of
death listed as the cause, no cause of death listed at
all) were clearly identifiable from a simple review
of each certificate.
To ensure lack of bias, two pathologists randomly
reviewed 20 of the selected death certificates and
recorded their findings. We agreed on each category.
Results
I retrieved 1729 death certificates from the hospital
records, but excluded 41 because they were earlier
than 2 days, for a total of 1688 death certificates that
met the inclusion criteria. The deceased persons were
mostly men (66.4%). Mean age was 62 years (range
14–114, SD ¼ 20.89).
I identified no category I or II errors in the reports.
I identified category III errors in 75% (1266) of the
reports: only 25% (424) listed the conditions that may
have led to death, and of these, only 30 (2%) correctly
listed the conditions in the appropriate row or col-
umn. Correct cancer-related causes of death included
colon, prostate, breast, and liver cancer, but detail was
often lacking (histology type, locality). Errors in can-
cer-related causes of death included nonspecific label-
ling such as “cancer,” “tumor,” “metastatic tumor,”
“brain tumor,” or “colon tumor.” Correct non-cancer-
related causes of death included diabetic ketoacidosis,
pneumonia, meningitis, gastrointestinal hemorrhage
and perforation, or traffic accident, but records lacked
essential details such as the causative organism or
complications leading to death.
I found category IV errors (wrong cause or manner
of death) in all (100%) records, meaning that an
incorrect cause of death was listed, or cause of death
was absent. Of these, 1186 (70%) listed
“cardiopulmonary arrest” as the cause of death; the
rest listed comorbidities or mechanisms—such as
chronic ischemic heart disease, myocardial infarction,
malignancy, renal failure, diabetes and even “traffic

accident”—rather than the specific cause. Similarly,
4% listed different types of organ failure (e.g., heart,
kidney, liver, and multiorgan), but these were mecha-
nisms of death, rather than causes. Diabetes was listed
as a cause in 2% of records without clearly stating a
complication causing death. “Traffic accident” lacked
the detail of the sequence of events leading to death
and suggested a manner of death that may not have
been a cause (e.g., not all traffic collisions are acci-
dents, and traffic or transportation injuries may occur
in cars, on motorbikes or bicycles, to drivers, passen-
gers, or pedestrians).
Discussion
In the records we evaluated for the present study, all
mandatory sections had been completed (we found no
abbreviations or shorthand), no diagnoses not listed in
a logical order, and no missed comorbidities contribu-
ting to death; known clinical diagnosis not completely
specified (i.e., no category I or II errors); this was
similar to Pandya, Bose, Shah, Chaudhury, and Phatak
(2009). We expected to find no category I errors,
because no death certificate can be submitted at King
Khalid University Hospital if the mandatory sections
are incomplete. If any such errors had been identified,
the responsibility for addressing them would lie
equally with the physician who completed the certifi-
cate and the hospital administration. The finding of a
lack of abbreviations or illegible shorthand was a posi-
tive result; it is easy for physicians, who come into
repeated contact with the same diseases and condi-
tions, to abbreviate names and symptoms uncon-
sciously (Parvaiz, Subramanian, & Kendall, 2008;
Sinha, McDermott, Sriniva, & Houghton, 2011).
Hospital administration will reject any death certifi-
cates that contain abbreviations because abbreviations
may be misinterpreted (e.g., RTA could mean renal
tubular acidosis or road traffic accident) or simply not
understood. The fact that we did not find these types
of errors may indicate that physicians are aware of the
drawbacks of abbreviation and are actively seek to
counter it in important documentation.
Concerning category III errors (missing or misclas-
sified cause of death), most reports contained no valid
chain of events in the appropriate section. In most
cases, the records provided were a list of some or all
of an individual’s conditions, but did not establish a
causal link or indicate relevance. This finding has sev-
eral possible explanations: that physicians do not
know how to correctly determine what comorbidities
DEATH STUDIES 3
or series of events constitute the chain leading to a
patient’s death; high-pressure work and time con-
straints; or that the wording or construction of the
death certificate makes it unclear what should be
entered (Pritt, Hardin, Richmond, & Shapiro, 2005).
Further research is needed to determine which of
these factors or combination of factors best explains
the high rate of category III errors (missing or mis-
classified cause of death) found in this study
All studied records had category IV errors (wrong
cause or manner of death). These were errors in iden-
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
finding needs to be taken seriously by issuing institu-
tions and the government bodies that supervise them.
If all certificates incorrectly list cause of death, legal
proceedings (insurance, compensation) and national
statistics on epidemiology and quality of life will be
based on incorrect information and could lead to
errors in resource allocation (Pandya, Bose, Shah,
Chaudhury, & Phatak 2009; Russell & Conroy, 1991).
Other studies have found substantial error rates
relating to recorded cause of death. In an audit of
practice, 55% of death certificates had been com-
pleted to minimum standards, and many were miss-
ing information (Swift & West 2002). Similar to the
findings of the present study, at a teaching hospital
in India, 78.1% of death certificates contained errors
related to cause of death (Pandya, Bose, Shah,
Chaudhury, & Phatak 2009). Additionally, death cer-
tification errors were identified in 82% of death cer-
tificates (category I, II, III, and IV errors in 72%,
32%, 31%, and 17%, respectively) (Pritt, Hardin,
Richmond, & Shapiro 2005). The fact that the death
certificates in the present study showed no category
I or II errors may be explained by rigorous admin-
istrative rules and feedback at King Khalid
University Hospital. The higher rates of category III
and IV errors may have been due to perceived lack
of importance of the death certificate, or to lack of
knowledgeable feedback. I suggest that the design of
the local death certificate is difficult to follow for
physicians and completely lacks any instructions.
Additionally, there are no courses for death certifi-
cation at any teaching level. Furthermore, there
should be a committee that reviews death certificates
to guarantee quality.
The limitations of this study include that it is retro-
spective. Future studies designed to be prospective will
4 K. ALJERIAN
be of higher yield. Additionally, the study focused on
one hospital. A multicenter approach will give a better
idea of the death certification errors issue.
Finding out how the level of error we found was
permissible over a 20-year period and pinpointing the
source of the problems needs to be a high priority.
Future investigations should evaluate variables that
may impact error rates in death certificate reporting;
checks that are run on submitted reports; training of
physicians in certificate preparation and evaluation;
and whether other institutions in Saudi Arabia have
similar error rates.
Conclusion
Proper completion of death certificates is vital for
many legal and governmental practices at the national
level. This study found that although physicians com-
pleted all necessary fields and actively countered the
use of abbreviations when filling out death certificates,
they often failed to correctly identify contributing
comorbidities and events leading to death. All certifi-
cates listed an incorrect cause of death, making them
useless for government, legal, or even personal use.
Further large-scale studies should be conducted in
other hospitals, and the exact source of these
errors identified.
Acknowledgements
The author would like to acknowledge the College of
Medicine, King Saud University (CMRC-College of medi-
cine research center) for their support.
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