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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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.

9. 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.

10. 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.

11. 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.

12. Resources CDC Medical examiners handbook
CDC guidelines for determining suicide:
US instructions for completing the medical certificate in cases of injury or poisoning (external causes)
US instructions for completing the medical certificate after hurricanes
Discuss some examples here.