Autopsies and death certification in deaths due to blunt trauma: what are we missing?
OBJECTIVES: To determine the frequency, body region and severity of injuries missed by the clinical team in patients who die of blunt trauma, and to examine the accuracy of the cause of death as recorded on death certificates. DESIGN: A retrospective review. SETTING: London Health Sciences Centre, London, Ont. PATIENTS: One hundred and eight deaths due to blunt trauma occurring during the period Apr. 1, 1991, to Mar. 31, 1997. Two groups were considered: clinically significant missed injuries were identified by comparing patient charts only (group 1) and more detailed injury lists from the autopsies and charts of the patients (group 2). OUTCOME MEASURES: Chart and autopsy findings. RESULTS: Of the 108 patients, 78 (72%) were male, and they had a median age of 39 years (range from 2 to 90 years). The most common cause of death was neurologic injury (27%), followed by sepsis (17%) and hemorrhage (15%). There was disagreement between the treating physicians and the causes of death listed on the death certificate in 40% of cases and with the coroner in 7% of cases. Seventy-seven clinically significant injuries were missed in 51 (47%) of the 108 patient deaths. Injuries were missed in 29% of inhospital deaths and 100% of emergency department deaths. Abdominal and head injuries accounted for 43% and 34% of the missed injuries, respectively. CONCLUSIONS: The information contained on the death certificate can be misleading. Health care planners utilizing this data may draw inaccurate conclusions regarding causes of death, which may have an impact on trauma system development. Missed injuries continue to be a concern in the management of patients with major blunt trauma. (+info)
What is a natural cause of death? A survey of how coroners in England and Wales approach borderline cases.
AIM: Many deaths fall in the "grey" area between those that are clearly natural and those that are unnatural. There are no guidelines to help doctors in dealing with such cases and death certification is often arbitrary and inconsistent. In an attempt to initiate debate on these difficult areas, and with the ultimate aim of achieving national consensus, the views of coroners in England and Wales were sought. METHODS: Sixteen clinical scenarios, with causes of death, were circulated to all coroners in England and Wales. For each case they were asked to provide a verdict, with explanation. The deaths fell into three groups: (1) postoperative, (2) a combination of trauma and natural disease, and (3) infectious disease. RESULTS: Sixty four questionnaires were returned. There was near consensus (> 80% concordance) in only two of the 16 cases. In five, there was no significant agreement between coroners in the verdicts returned ("natural causes" versus "misadventure/accidental"). These included all three cases in which death resulted from a combination of trauma and natural disease (a fall after a grand mal fit; falls resulting in fractures of bones affected by metastatic carcinoma and osteoporosis), bronchopneumonia after hip replacement for osteoarthritis, and new variant Creutzfeldt-Jakob disease. The comments made for each case indicate that the variation between coroners in whether or not to hold an inquest, and the verdict arrived at, reflect the lack of a definition for natural causes, together with differences in the personal attitudes of each coroner. CONCLUSIONS: There is considerable variation in the way in which coroners approach these borderline cases, many of which are common in clinical practice. This study indicates a need for discussion, working towards a national consensus on such issues. It highlights the importance of good communication between coroners and medical staff at a local level. (+info)
Are coroners' necropsies necessary? A prospective study examining whether a "view and grant" system of death certification could be introduced into England and Wales.
AIMS: To determine whether the cause of death could be accurately predicted without the need for a necropsy, and thus to consider whether a "view and grant" system of issuing a cause of death could be introduced into England and Wales. METHOD: A one year prospective necropsy study was performed incorporating 568 deaths. Before necropsy, in each case the cause of death was predicted from the available history without examination of the body, and this cause was then compared with the cause of death found at necropsy. RESULTS: The ability of the pathologist involved in the study to predict a cause of death before necropsy, either while in the mortuary or as a paper exercise, was shown to vary between 61% and 74% of cases. After the necropsy, the number of correct predicted causes of death ranged from 39% to 46%. Ischaemic heart disease was found to be the most common and most accurately predicted cause of death. Some natural diseases were frequently misdiagnosed, whereas certain types of unnatural disease were always identified correctly. CONCLUSIONS: This study highlights the advantages and disadvantages of a view and grant system. Although it identifies a potential use of such a system, in some cases such as natural cardiac disease, because of the potentially high diagnostic error rate, the continuation of the present system of postmortem examination as part of the coroner's enquiry is recommended. (+info)
Improving the National Board of Medical Examiners internal Medicine Subject Exam for use in clerkship evaluation.
OBJECTIVE: To provide a consensus opinion on modifying the National Board of Medical Examiners (NBME) Medicine Subject Exam (Shelf) to: 1) reflect the internal medicine clerkship curriculum, developed by the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM); 2) emphasize knowledge important for a clerkship student; and 3) obtain feedback about students' performances on the Shelf. DESIGN: Two-round Delphi technique. PARTICIPANTS: The CDIM Research and Evaluation Committee and CDIM members on NBME Step 2 Committees. MEASUREMENTS: Using 1-5 Likert scales (5 = highest ratings), the group rated test question content for relevance to the SGIM-CDIM Curriculum Guide and importance for clerkship students' knowledge. The Shelf content is organized into 4 physician tasks and into 11 sections that are generally organ system based. Each iteration of the Shelf has 100 questions. Participants indicated a desired distribution of questions by physician task and section, topics critical for inclusion on each exam, and new topics to include. They specified the types of feedback clerkship directors desired on students' performances. Following the first round, participants viewed pooled results prior to submitting their second-round responses. RESULTS: Of 15 individuals contacted, 12 (80%) participated in each round. The desired distribution by physician task was: diagnosis (43), treatment (23), mechanism of disease (20), and health maintenance (15). The sections with the most questions requested were the cardiovascular (17), respiratory (15), and gastroenterology (12) sections. The fewest were requested in aging/ethics (4) and neurology, dermatology, and immunology (5 each). Examples of low-rated content were Wilson's Disease, chancroid and tracheal rupture (all <2.0). Health maintenance in type 2 diabetes, hypertension, and cardiovascular disease all received 5.0 ratings. Participants desired feedback by: section (4.6) and physician task (3.9), on performances of the entire class (4.0), and for individual students (3.8). CONCLUSION: Clerkship directors identified test content that was relevant to the curricular content and important for clerkship students to know, and they indicated a desired question distribution. They would most like feedback on their students' performance by organ system-based sections for the complete academic year. This collaborative effort could serve as a model for aligning national exams with course goals. (+info)
Surveillance for anthrax cases associated with contaminated letters, New Jersey, Delaware, and Pennsylvania, 2001.
In October 2001, two inhalational anthrax and four cutaneous anthrax cases, resulting from the processing of Bacillus anthracis-containing envelopes at a New Jersey mail facility, were identified. Subsequently, we initiated stimulated passive hospital-based and enhanced passive surveillance for anthrax-compatible syndromes. From October 24 to December 17, 2001, hospitals reported 240,160 visits and 7,109 intensive-care unit admissions in the surveillance area (population 6.7 million persons). Following a change of reporting criteria on November 8, the average of possible inhalational anthrax reports decreased 83% from 18 to 3 per day; the proportion of reports requiring follow-up increased from 37% (105/286) to 41% (47/116). Clinical follow-up was conducted on 214 of 464 possible inhalational anthrax patients and 98 possible cutaneous anthrax patients; 49 had additional laboratory testing. No additional cases were identified. To verify the limited scope of the outbreak, surveillance was essential, though labor-intensive. The flexibility of the system allowed interim evaluation, thus improving surveillance efficiency. (+info)
On November 19, 2001, a case of inhalational anthrax was identified in a 94-year-old Connecticut woman, who later died. We conducted intensive surveillance for additional anthrax cases, which included collecting data from hospitals, emergency departments, private practitioners, death certificates, postal facilities, veterinarians, and the state medical examiner. No additional cases of anthrax were identified. The absence of additional anthrax cases argued against an intentional environmental release of Bacillus anthracis in Connecticut and suggested that, if the source of anthrax had been cross-contaminated mail, the risk for anthrax in this setting was very low. This surveillance system provides a model that can be adapted for use in similar emergency settings. (+info)
Coverage of work related fatalities in Australia by compensation and occupational health and safety agencies.
AIMS: To determine the levels of coverage of work related traumatic deaths by official occupational health and safety (OHS) and compensation agencies in Australia, to allow better understanding and interpretation of officially available statistics. METHODS: The analysis was part of a much larger study of all work related fatalities that occurred in Australia during the four year period 1989 to 1992 inclusive and which was based on information from coroners' files. For the current study, State, Territory, and Commonwealth OHS and compensation agencies were asked to supply unit record information for all deaths identified by the jurisdictions as being due to non-suicide traumatic causes and which were identified by them as being work related, using whatever definitions the agencies were using at the relevant time. This information was matched to cases identified during the main study. RESULTS: The percentage of working deaths not covered by any agency was 34%. Only 35% of working deaths were covered by an OHS agency, while 57% were covered by a compensation agency. The OHS agencies had minimal coverage of work related deaths that occurred on the road (to workers (8%) or commuters (3%)), whereas the compensation system covered these deaths better than those of workers in incidents that occurred in a workplace (65% versus 53%). There was virtually no coverage of bystanders (less than 8%) by either type of agency. There was marked variation in the level of coverage depending on the industry, occupation, and employment status of the workers, and the type of injury event involved in the incident. CONCLUSIONS: When using data from official sources, the significant limitations in coverage identified in this paper need to be taken into account. Future surveillance, arising from a computerised National Coroners Information System, should result in improved coverage of work related traumatic deaths in Australia. (+info)
Necropsy practice after the "organ retention scandal": requests, performance, and tissue retention.
AIMS: After the so called "organ retention scandal" in the UK this study set out to assess the impact on death certification and hospital (consent) necropsies, including the postmortem retention of tissues and organs. METHODS: Data were prospectively gathered over a one year period for all deaths occurring at the Royal Hallamshire Hospital, Sheffield, UK to determine the frequencies with which death certificates were completed and necropsies were requested. The seniority of the clinician undertaking these duties was recorded. Pathologists were asked to record the extent of every necropsy during the study period. The type and planned uses of tissues retained were recorded. RESULTS: Death certificates were issued for 88.5% of the 966 deaths for which clinicians completed proformas. Of these, 88.9% were issued by preregistration and senior house officers. Consent was sought for a necropsy in 6.2% of cases (usually by non-consultant staff) and was granted in 43.4% of these. The overall, medicolegal, and hospital necropsy rates were 13.4%, 9.9%, and 3.5%, respectively. Tissues were retained from 55.4% of necropsies for diagnostic purposes, although sampling does not appear to be systematic. CONCLUSIONS: Death certification and seeking consent for a necropsy are frequently delegated to junior clinical staff. This may explain the low standard of death certification reported by others and the low necropsy rate. The decline in the necropsy rate and the low rate of sampling for histological examination highlight the decline of the hospital necropsy and the lack of a systematic approach to tissue sampling. (+info)