Lijken: Medical death certification by forensic physicians in the Netherlands: Validity and interdoctorvariation, JFLM 2016


Authors: Tina Dorn, Manon Ceelen, Udo Reijnders, Kees Das.


The aim of the study was to assess interdoctorvariation and validity in death certification by forensic physicians using 19 written scenarios. The scenarios described typical cases from forensic-medical practice. Physicians were asked to determine the manner of death (natural/unnatural) and to provide an ICD-10 code for the cause of death. In contrast to most studies on this topic, the measure of agreement among physicians was chance-corrected and a standard was used to assess the correctness of the assigned cause and manner of death. Forty-seven physicians participated in the survey. The study demonstrated that forensic physicians varied widely in their conclusions. With respect to manner of death, adequate agreement (defined as kappa>0.70) was achieved in six scenarios (32% of all scenarios).

Concerning the underlying cause of death, adequate agreement was reached in three cases (16% of all scenarios). Furthermore, predictors for the correctness of manner and cause of death were studied using logistic regression. Years of experience as a forensic physician significantly predicted the correctness of cause of death (p < 0.05). Other predictors remained insignificant. With regard to manner of death, none of the studied predictors proved to be significant. To conclude, there appears to be a lack of consistency among forensic physicians regarding death certification. The ICD-10 coding of causes of death applied by forensic physicians is questionable. Less experienced physicians need supervision by more experienced colleagues when making judgments concerning the cause of death. Altogether, there is an urgent need to work out consensus-based guidelines for forensic physicians on how to certify deaths.