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For your convenience below are numerous articles from reputable medical journals and other affiliated resources that easily point to the established normative accounts of inaccuracies taking place in the death certificate process.

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Death Certification Errors and the Effect on Mortality Statistics

From: Public Health Reports 2017,

Vol. 132(6) 669-675

"Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code."

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Autopsy Service Death Certificate Review

From: Archives of Pathology & Laboratory Medicine, (2020) 144 (9): 1092–1096

"During this time, 590 death certificates were issued by the hospital. Eighty-eight of 590 (15%) were amended. Of those 88 amended, 41 (47%) were missing an underlying cause of death, 7 (8%) had an inaccurate cause of death, 41 (47%) failed to include relevant contributory causes of death..."

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Principles and Pitfalls: A Guide to Death Certification

From: Clinical Medicine & Research 2015, Volume 13, Number 2: 74-82

"The reported cause of death is the best medical opinion of the certifier, and it is understood that this opinion may change if additional information later becomes available. Most states have provisions to amend death certificates."

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Problems With Proper Completion and Accuracy of the Cause-of-Death Statement

From: Arch Intern Med. 2001;


"Of the 494 death certificates, 204 (41%) contained improperly completed CODs. Of these, 49 (24%) contained major discrepancies between clinicians' and pathologists' CODs. Of the 494 death certificates, 290 (59%) had properly completed CODs. Of the 290 properly completed CODs, 141 (49%) contained disagreements: 73 (52%) on underlying CODs; 44 (31%) on immediate CODs; and 47 (33%) on other significant conditions (part II)."

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Accuracy of Death Certification in Two Tertiary Care Military Hospitals

From: Mil Med. 1999


"We suggest that the data derived from our institutions are not unique; in fact, our experience at several academic and private hospitals suggests that this problem is widespread."

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Systematic Review of Statistics On Causes of Deaths in Hospitals

Bull World Health Organ 2014;


Objective: To systematically review the reliability of hospital data on cause of death and encourage periodic reviews of these data using a standard method.


Conclusion: The assumption that causes of death are being accurately reported in hospitals is unfounded. To improve the reliability and usefulness of reported causes of death, national governments should do periodic medical record reviews to validate the quality of their hospital cause of death data, using a standard.

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Death Certification and Doctors' Dilemmas: A Qualitative Study of GP's Perspectives

From: British Journal of General Practice, September 2005

"The possible bias of GPs to accommodate the interests of the deceased’s family, and/or cultural mores needs to be acknowledged. A consultation process, with colleagues or coroners, may reduce uncertainty about the cause of death if there has been uncertainty in the clinical setting. These perspectives need to be integrated into education for medical students and GPs."

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Medicolegal Issues:

Death Certificates

From: Proc (Bayl Univ Med Cent) 2006;19:285–286

"The cause of death documented in the decedent’s death certificate may very well be the most significant single piece of legal evidence in any dispute in which the cause of death is at issue. In fact, because of certain statutory provisions, what is documented on the death certificate might arguably be more important than what is found on autopsy. 

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A Mixed-Methods Prospective Study of Death Certification In General Practice

From: Family Practice, Volume 27, Issue 3, June 2010, Pages 351–355

"Family issues. This theme related to the matters raised by families of the deceased, relating to the certification of death. Participants mentioned many times that bereaved families may not want post-mortems, even where there may be some doubt about the specific diagnosis... One comment related to GPs being honest with families about the level of uncertainty: ‘. . . we have choice. If you do express uncertainty at the time of death, some families actually appreciate honesty and they say ‘‘we really want to know’’. Nine times out of ten they accept the uncertainty with you. But where they don’t say that, then problems can start."

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Misdiagnosis: Analysis Based On Case Record Review With Proposals Aimed To Improve Diagnostic Processes

From: Clinical Medicine 2011,

Vol 11, No 4: 317–21

"Accurate diagnosis requires integrating correct clinical findings with appropriate investigations and framing conclusions accurately. Intuitive thought and action play an important role in this endeavour and will continue to do so. Trainees, however, have to learn to remain open-minded in order to counteract natural biases in human thought processes. It seems reasonable to suggest that they should be taught to be aware of such biases and so take steps to counteract. This requires reflection, discussion and reconsideration. If still in doubt there will be a need for a second opinion. Ideally that second opinion should come from a more experienced clinician who must be prepared to analyse the problem without being biased by previous assessments."

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