An Audit of Death Certification at a District General Hospital

Hannah BarrettMedical Student

Imperial College London

The Question

• How well are death certificates completed at University Hospital of North Durham?

• Do doctors need further advice on how to complete death certificates correctly?

Method

• First 100 death certificates in July– mortuary records

• Recorded – date of death– ward – cause of death cascade

Method

• Cause of death cascades were reviewed and graded– Two histopathologists separately

• Disagreement– Consensus meeting (third tie breaker)

Grading

Part 1

Logical certificate, completed appropriately (1)

Logical certificate but with minor errors (2)

Illogical or inappropriately completed certificate (3)

Certificate completed in a manner which should have been rejected by the Registrar (4)

Grade 1 Grade 3

1a Pneumonia

b Immobility

c Stroke

2 Peripheral vascular disease

1a Lung cancer

b Advanced dementia, frailty of old age and anaemia

c Chest infection

Grading

Part 2

Correctly used

Contained information which should have been included in Part I

Irrelevant information included

Contained information both non-specific and incorrect

Grading

49

15

31

5

1

2

3

4

Use of Part 2

38

29

29

4Irrelevant

OK

Part I

Non specif icand w rong

Number of deaths in each ward over the study time period

0

5

10

15

20

25

Res

pira

tory

Eld

erly

car

e

Car

diol

ogy/

Dia

bete

s

Med

ical

Adm

issi

ons

Gas

troe

nter

olog

y

Eld

erly

car

e/D

emen

tia/

Rhe

umat

olog

y

Sur

gica

l war

ds(c

ombi

ned)

Oth

er

Ward

Nu

mb

er o

f d

eath

s

By organ system

9

18

33

15

25 Elderly

GI/Gastro

Respiratory

Other

Cardiovascular

Difficult certificates

% Pneum Sepsis FoOA CVD Neop

1 25.5 28.6 21.7 58.3 69.2

2 4.3 57.1 34.8 25.0 7.7

3 63.8 0 34.8 16.7 15.4

4 6.4 14.3 8.7 0 7.7

Inter-observer variation

• 23 cases rated differently

• Fleiss kappa results = 0.63 – Substantial agreement

Complexity

• Was a longer (? more complicated) certificate more likely to be wrong?

Training

• Already received– Undergraduate instruction– Preparing for practice– Induction– Interactive session early in training

Conclusions

• Despite efforts to educated junior doctors avoidable errors are frequently made– Guidance (ONS) Sept 08

• Part II often a waste paper basket

Conclusions

• Poor– Infections (especially pneumonia) – Frailty of old age

• Good– Malignancy – Cardiovascular

Action

• Focused interactive session• Further interventions

– Individual performance data– Approachable source of assistance– Formal policy potentially leading to remedial

action– Discussion group session

• Reaudit