Correct determination of the cause and manner of death is only rarely taught in medical training and, as a result, misclassification is common. The correct primary cause of death is the disease process or non-natural event that primarily led to the death in the most direct fashion via a direct mechanism. Other comorbid factors are properly listed as contributory if they played any role in hastening or contributing to the primary factors leading to the death.
In almost every jurisdiction, deaths that may have a non-natural contributory factor (e.g., accident, assault, intoxication) must be referred to the coroner or medical examiner with jurisdiction. This is because clinical physicians receive no training in proper certification of these death. The specialty of forensic pathology specifically deals with non-natural deaths and, as a result, only a medical examiner or coroner’s physician (a physician acting as an agent of a coroner) are legally allowed to sign death certificates on non-natural deaths in most states. Unfortunately, since clinical physicians do not certify non-natural deaths, they are often unaware of their correct methodology for classification and, therefore, many non-natural deaths are not properly reported to the authorities. This is particularly true if the non-natural event was in the remote past.
To correctly determine the manner of death, a decision must be made whether the event in question contributed to the death in any way. Deaths that were preceded by trauma or other non-natural factor, even in the remote past, must be classified according to the non-natural event regardless of any natural disease processes that may also have contributed. The fractional portion that the non-natural event contributed to the death, even if relatively minor, is irrelevant. In other words, the non-natural event does not have to be sole cause of death or even a majority contributor to the cause of death. Any degree of causation warrants classification as non-natural. The time delay between the non-natural event and the death is also irrelevant for legal classification purposes. As an example, a soldier shot and paralyzed by a sniper during the Vietnam War died decades later from urosepsis resulting from his chronic indwelling urinary catheter. That case was properly classified as a homicide due to the direct causal link between his trauma and eventual death.
Standard guidelines that forensic pathologists follow when determining the correct manner of death classification refer to the “but for” principle. If a death would not have occurred at the time it did without the non-natural event, the death must be classified as non-natural. That means that if an accident—in any way—led to or contributed to hastening of a death, then the manner of death must be classified as accident. This is true regardless of the degree of contribution to the death or the time delay between the event and death. As a rule, in forensic pathology when considering accidental injuries, if a person does not return to their physiologic baseline after an accident there is a high likelihood of the accident contributing to the death.
This is an extremely common scenario in forensic pathology because it deals with non-accidental deaths routinely. Most clinical physicians are not trained to recognize when a trauma (especially remote trauma) contributes to a death. To be fair, clinical physicians are focused on taking care of their living patients and very few have any training in correct death certification. Many times, misclassified deaths are caught by the official (e.g., county clerk, vital statistics registrar) recording the death certificate when they recognize that an injury is listed on the death certificate, but the death is classified incorrectly as natural. Those cases are then referred to medical examiners for review and correction. In other cases, the erroneous classifications are not caught on review and are brought to our attention by funeral directors or family members and then a medical examiner assumes jurisdiction. Unfortunately, some death certificates are filed even though classified incorrectly because of the absence of that information on the death certificate and because the signer of the death certificate did not recognize the contribution from the traumatic event. As a result of such a misclassification, not only are death statistics less accurate but adverse effects on the decedent’s family are common.