MEDICAL CERTIFICATION OF Cause of death DEATHS due to External Causes TONGA - DEC 2018

Deaths due to External Causes Injuries are some of the most poorly certified causes of death in the Pacific Islands. Most end up as “injury – non-specified” In order to record the underlying cause of death we need both: 1. THE INJURY + 2. HOW THE INJURY OCCURRED 3. THE MANNER OF THE DEATH

1. The INJURY EXAMPLES Bleeding from a head wound Poisoning Crush injury to chest Medical certificate examples: In both cases we need MORE information on how the injury occurred Toxic shock due to Septicaemia Infected wound (right leg) Exsanguination Penetrating stab

2. HOW the INJURY OCCURRED EXAMPLES INCLUDE Ingestion of chemical/ fish/ etc - specify what was ingested if known Stabbing wound Hanging Drowning MVA - detail of the type of vehicle, and passenger/driver/ pedestrian if possible. Fall – specify if this was a fall off something or something falling onto them and what this object was

2. HOW the INJURY OCCURRED (cont’d) Medical certificate examples: Toxic shock due to Septicaemia Infected wound (Right leg) Crush injury from Motor bike crash Exsanguination Penetrating stab wound to abdomen Spear gun injury

3. Manner of death Should be recorded for all external causes Options are: (NATURAL) Accidental Intentional self harm Assault Not known Common issues include: Hanging (should only be counted as suicide if this is specifically noted) Drowning Poisoning (very different codes for accidental ingestion vs deliberate self- harm); however “not known” ends up in a separate category of “injury – other” in the General mortality list Ingestion of chemical/ fish/ etc - specify what was ingested if known Stabbing wound Hanging Drowning MVA - specify detail of they type of vehicle, and passenger/ driver/ pedestrian if possible. Fall – specify if this was a fall off something or something falling onto them and what this object was

3. MANNER Of DEATH Medical certificate examples: UCOD: Motorbike crash UCOD: Accidental injury Toxic shock due to Septicaemia Infected wound (Right leg) Spear gun injury Crush injury from Motor bike crash (accident) Exsanguination Penetrating stab wound to abdomen Spear gun injury (accident – self inflicted)

3. Manner of death Unless legislation has assigned determining the manner of death elsewhere (such as a coroner or police investigation), this should be included on the medical certificate by the certifying doctor – to the best of their ability Things to consider when determining the ‘manner of death’: The type, location and characteristics of the injury itself Documented history (ie previous self-harm intents) Family report/ witnesses etc Evidence of intent to act (saying goodbye, closing accounts etc) Where there is concern (e.g. Assault) – follow local policy on referring cases to medical supervisor and/or police Discuss some examples here.

Road-Traffic Related Deaths Few countries have reliable data on road traffic injuries A comprehensive assessment of the magnitude of road traffic injuries should consider fatal and nonfatal injuries, resulting disability, the economic cost of road crashes, injuries and the cost effectiveness of interventions. Very few countries in the Pacific Islands can effectively identify motor vehicle accidents/crashes in their crash data. Discuss some examples here.

POISONING (intentional vs Non-intentional) Multiple possibilities when someone is recorded as having died from “poisoning” This usually means either: Accidental – ingestion of chemical or toxic substance (child ingesting cleaning fluid, mushrooms, fish toxin), smoke inhalation, overdose of a recreational drug etc. Intentional self-harm - i.e. paraquat poisoning The substance and means by which it was consumed (ingested/ inhaled/ injected etc) should be noted if known; as well as the intent. Discuss some examples here.

Deaths due to a Natural disaster When a death occurs due to a natural disaster – the cause should be specified as normal. However if the physician believes that the death was related to the natural disaster -this should be recorded in the contributory causes The collection of statistics on the impact of a natural disaster is essential, but often this information cannot be obtained from the Health services and comes from unverified reports through the Emergency Management System.

Resources CDC Medical examiners handbook https://www.cdc.gov/nchs/data/misc/hb_me.pdf   CDC guidelines for determining suicide: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001318.htm US instructions for completing the medical certificate in cases of injury or poisoning (external causes) https://www.cdc.gov/nchs/data/dvs/red_form.pdf US instructions for completing the medical certificate after hurricanes https://www.cdc.gov/nchs/data/dvs/hurricane_certification.pdf Discuss some examples here.