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Medical certification of cause of death

External causes of death

A common problem in many countries is that deaths due to external or unnatural causes are underreported because many certifiers are unaware of the correct method of certifying such deaths. ‘External causes’ include injury, poisoning or other consequences of external events. In these cases, the certifier must record both the circumstances and consequences of the incident that resulted in death. 

Although the ICD provides special instructions on how to classify unnatural deaths, certifying physicians are not always aware of the guiding rules and principles. As a result, physicians may report the immediate COD rather than the circumstances that led to the death. For example, in the case of an accidental road traffic death, the accident itself should be given as the UCOD, in addition to the immediate COD (eg intracranial haemorrhage). The logic here is that the death would not have taken place if the accident had not occurred in the first place, and that is what needs to be highlighted, and identifiable, in the COD statistics.


Another reason for the inaccurate reporting of deaths due to external causes is that in most countries deaths due to accidents and violence must be investigated by the police or coroner. In these cases, the COD may initially be registered as ‘not defined’ or ‘unknown’ pending the outcome of the investigation. It is then common for significant delays to occur in finalising the data, with the true COD not being accurately reflected in the resulting vital statistics.

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