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. 2021 Jul 8;11(2):103–111. doi: 10.1177/19253621211027747

Legal Frameworks: A Starting Point for Strengthening Medicolegal Death Investigation Systems and Improving Cause and Manner of Death Statistics in Civil Registration and Vital Statistics Systems

Olga Joos ✉, Srdjan Mrkic, Lynn Sferrazza
PMCID: PMC8408807  PMID: 34567329

Abstract

Medicolegal death investigation systems, which generally fall within one of three types—medical examiner, coroner, or law-enforcement-led systems—investigate deaths that are unnatural or suspicious. The current quality of cause of death statistics on deaths investigated within medicolegal death investigation systems globally limits effective public health response. A starting point to strengthening global medicolegal death investigation systems and improving the quality of cause and manner of death reported to civil registration systems is through a strong legal framework. Two resources, the United Nations Statistics Division Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management and the Global Health Advocacy Incubator Legal and Regulatory Toolkit for Civil Registration, Vital Statistics and Identity Management, present recommendations and provide guidance to country stakeholders in reviewing and revising their medicolegal death investigation legal frameworks. Physician determination of cause and manner of death, defined criteria for case referral to the medicolegal death investigation system, an amendment process, and investigation collaboration are four core considerations for medicolegal death investigation system legal frameworks. A strong medicolegal death investigation legal framework is a necessary starting point, but it is not sufficient for ensuring the timely, accurate, and complete reporting of cause and manner of death in national vital statistics.

Keywords: Forensic pathology, Legal framework, Mortality statistics, Medicolegal, Civil registration, Vital statistics

Introduction

According to the United Nations, a civil registration system supports the “continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events pertaining to the population, as provided through decree or regulation in accordance with the legal requirements in each country” (1). At the individual level, civil registration bestows one’s human right to a legal identity and access to social services provided by the state (2,3). At the population level, civil registration provides valuable data for the production of vital statistics, which also have economic, social, and political benefits (3). Due to their critical role, civil registration systems are underpinned by legal frameworks, some dating back to the 18th century (4).

The recent pandemic has highlighted the need for timely, accurate, and complete mortality data, which is best collected from civil registration systems as they are designed to capture all deaths (5). Despite the essential role of civil registration in producing data for vital statistics, civil registration and vital statistics (CRVS) systems in only one-third of countries produce high-quality cause of death data (6). Of further concern is the quality of cause of death data for deaths investigated within the medicolegal death investigation (MLDI) system, a separate system connected to the civil registration system for certain deaths. The MLDI systems generally fall within one of three types—medical examiner, coroner, or law-enforcement-led systems—and investigate deaths that are unnatural or suspicious, such as homicides, suicides, and accidents.

The MLDI system is a complex system with many stakeholders, some of whom conduct investigations required for the medical determination of cause and manner of death, impacting the quality of cause of death data in national vital statistics systems. A study in France found that only a percentage of suicides were included in national statistics due to system complexities (7). Studies have found fatal injuries under-reported in national statistics by 10% to 20% in India and 12.6% in Brazil, as well as substantial differences in homicide rates reported by separate government agencies within South Africa (8 -10). Incomplete and inaccurate statistics minimize the burden of unnatural deaths and do not provide policy makers with the information necessary for targeted prevention measures.

Within the public health community, calls have been made to strengthen the civil registration systems for better quality vital statistics and specifically to improve the quality of injury mortality data (3,11,12). However, those efforts will not address the MLDI processes resulting in the under-reporting and unspecified reporting of unnatural deaths (7,9,13,14). Within the global MLDI community, calls have been made to strengthen MLDI systems and develop recommendations, including uniform legislation (13,15 -18). Given the differences in MLDI systems globally, a standard international model law may not be the best or most appropriate way to institute substantial changes. Instead, guidance that presents good practices for consideration within the various types of MLDI systems may better facilitate the adoption of legal provisions, where appropriate, that strengthen MLDI systems and their core functions, including the ability to capture complete and accurate data for inclusion in national vital statistics. This integration presupposes that a country maintains a civil registration system working to achieve or sustain quality standards such as accuracy, relevance, comparability, timeliness, and accessibility (3).

In the United States, a model law proposed in 1954 resulted in the transformation of MLDI systems to medical examiner systems in 22 US state and county jurisdictions between 1960 and 1996 (19). For the global community, the United Nations Statistics Division (UNSD), under its mandate to develop methodologies for CRVS systems, developed the Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management (UNSD Guidelines) (20). Noting the differences in MLDI systems, notably between coroner and medical examiner, the UNSD Guidelines introduce MLDI legal framework recommendations with a focus on the MLDI system’s role in the death registration process and the reporting of timely and accurate cause of death data. The development of UNSD Guidelines was subsequently followed by the development of the MLDI chapter of the Global Health Advocacy Incubator Legal and Regulatory Review Toolkit for Civil Registration, Vital Statistics and Identity Management (GHAI Toolkit), which guides country stakeholders in the review of their MLDI legal framework and presents good practices for consideration and deliberation in system revision efforts (21). Jointly, these resources fill a gap in MLDI system improvement recommendations for many countries, particularly those that maintain MLDI systems underpinned by legal codes from postcolonial independence or even from the late 19th century (22 -25).

This review presents four considerations for strengthening MLDI legal frameworks, which were drawn from the UNSD Guidelines and the GHAI Toolkit. They include physician determination of cause and manner of death, defined criteria for case referral to the MLDI system, investigation collaboration, and an amendment process. The recommendations are presented for consideration in all types of MLDI systems and in countries working to strengthen their CRVS systems through new or continuous quality frameworks. Additionally, this review presents legal frameworks as necessary for a strong MLDI system but not sufficient for ensuring the timely, accurate, and complete reporting of cause and manner of death in national vital statistics.

Discussion

Medicolegal Death Investigation System Legal Framework Resources

The UNSD Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management are a component of a comprehensive methodological framework for the United Nations Legal Identity Agenda (UN LIA), a holistic approach to civil registration, vital statistics and identity management, launched by the United Nations in 2020 (2). The legislative framework in principle is the critical piece of the UN LIA model as it provides legal protocols directing interoperability between different components of the system, spelling out responsibilities and ensuring protection of confidentiality of individual data.

The UNSD Guidelines present an elaboration of the necessary content of legislation in terms of the role of police, medical-legal officers, and emergency service requesting very specific provisions in respect of the role of the many actors in the medical legal system (20). Providing a more detailed presentation, the UNSD Guidelines focus on the process of registering an unnatural or suspicious death referred to a medicolegal office listing different solutions that need to be incorporated in the legislative framework, whether in the law itself or in the instructions and regulations, ensuring the proper and diligent registration of all unnatural deaths, including the cause and the manner of death.

Yet another part of the UNSD Guidelines focuses on the legal provisions for registering deaths in emergencies, disasters, or where there are no human remains spelling out the protocols, procedures and responsibilities, and the role of medicolegal authorities. Consequently, and fully aware of the different arrangements regarding the MLDI systems in United Nations Member States, the UNSD Guidelines provide clear and unambiguous advice in terms of the need to develop and adopt legislative framework that will ensure the universal registration of all deaths and the role and responsibilities of various institutions in that respect.

In collaboration with other D4H partners, the GHAI developed the Legal and Regulatory Toolkit for Civil Registration, Vital Statistics and Identity Management (CRVSID), which provides a guide for analyzing all the laws that support and pertain to a country’s CRVSID systems (21). Based on international best practices and good practices set out in documents from the United Nations, the World Health Organization, and other international bodies, the GHAI Toolkit helps government stakeholders to identify gaps or obstacles in their CRVSID legal framework and highlight opportunities for improvement. The GHAI Toolkit consists of 11 chapters, each of which addresses a specific aspect of CRVSID systems. Chapter 11 presents good practices and consideration for MLDIs, and through guided questions, assists country stakeholders in reviewing their MLDI system.

The UNSD Guidelines and the GHAI Toolkit present a broad range of considerations for MLDI legal frameworks. This review highlights four considerations drawn from these resources that play an important role in strengthening systems and improving the quality of cause and manner of death in national vital statistics.

Physician Determination of Cause and Manner of Death

A key focus of any MLDI system should be the production of good quality cause and manner of death determinations, which requires a physician in the medical evaluation component of the investigation. Physicians (note 1), with their knowledge in pathophysiology and differential diagnosis, have the skill and understanding to determine the sequence of injuries and medical conditions resulting in death. Therefore, medical certificate of cause of death (MCCD) forms should be completed by a physician and present his or her best medical opinion on the injuries and medical conditions that ultimately led to death (26). However, some MLDI systems are led by nonmedical professionals, which may be the case in law-enforcement-led systems and in certain jurisdictions in the United States, where coroners are elected and not required to have a medical background (27). Due to this, there has been a movement to incorporate physicians into MLDI systems. For example, starting in the 1860s in Maryland and spreading across the United States, coroner systems have been slowly transformed into medical examiner systems or hybrid coroner/medical examiner systems to include a physician in the death investigation process, as they play a critical role in the investigation and determination of cause and manner of death (15,19).

The GHAI Toolkit presents the rationale for physician inclusion in the various types of MLDI systems and processes and guides country stakeholders in evaluating their MLDI laws to define the role and participation of physicians in the MLDI system. An essential consideration in the role and placement of a physician in an MLDI system is the need for independence. In systems, where physicians operate within law enforcement or within the Ministry of Justice or Interior, care must be taken to ensure physician independence in fulfilling their medical services to the decedent without influence by the state (28). Similarly, in systems where the head of the MLDI system is an elected official (as is the case with some coroners in the United States), care must be taken to insulate the physician from political pressures (29).

It is important to note that physician involvement in the MLDI death certification process is necessary but not sufficient to achieve good quality cause and manner of death data. Physicians should be trained in the correct completion of the MCCD to improve the quality of cause and manner of death reported (12,30). Additionally, mortality coders should be trained in International Classification of Disease (ICD) coding to support the complex process of transforming medical expressions to their pertaining ICD codes and the application of rules to determine the underlying cause of death (12,30,31). A study by Bhalla et al. found that 24% of injury deaths reported in Great Britain and Northern Ireland and 18% of injury deaths in Australia were coded to unspecified unintentional injury, whereas the United States only had 5% of injury deaths coded as such (14). Unspecified mortality codes limit the public health response to an issue, as the prevention program should be tailored to address the cause (32).

Additionally, MLDI systems lacking a sufficient number of physicians trained in forensic medicine rely on general practitioners who are not trained to conduct the necessary investigations to identify cause and manner of death (17,18,22,23,33,34). Given the need for good quality cause of death statistics, efforts should be made to meet the human resource demands by improving forensic medicine training and making it more accessible for those interested in the specialty training (16,22,23,34).

Defined Criteria for Case Referral to the MLDI System

The percentage of deaths referred to the MLDI system range from 6% of total deaths in Catalonia to larger percentages among total deaths—15% of deaths in Australia, 20% in the United States, and 30% in Lyon, France (7,13,15,35). This variation stems from differences in the MLDI referral case criteria and MLDI system processes. In Bangladesh, law enforcement determines the cases for referral to the MLDI system, whereas in Italy, magistrates or prosecutors select cases for referral (18,22). The Indian Code of Criminal Procedure specifies cases for referral and allows determination of case referral by the investigating police (25). In general, law-enforcement-led systems tend to focus more narrowly on potential criminal cases, whereas medical examiner systems tend to focus more broadly on all unnatural deaths, including those where investigation of the cause of death is in the public interest. South Africa adopted national legislation in 2008 presenting broad categories for cases requiring referral leading to greater clarity on the cases requiring referral to the MLDI system (36). The UNSD Guidelines and GHAI Toolkit recommend defined criteria for case referral to the MLDI system, with the GHAI Toolkit providing further clarification on the rationale for these referrals.

After a case is referred to the MLDI system and jurisdiction is accepted, a determination must be made on whether to conduct an autopsy or an external examination for the determination of cause and manner of death. In many countries and systems, this determination is made by law enforcement, without the benefit of physician input, which may compromise the quality of cause of death information. In Italy and Uganda, law enforcement, rather than physicians in the MLDI system, determines the cases requiring autopsy (18,34). Due to a restrictive legal framework on forensic autopsy and budgetary limitations from competition with other police needs, forensic autopsy is limited to 1.5% of total deaths in Denmark (37,38). A study conducted in Australia found that forensic pathologists incorrectly determined cause of death in 28% of natural deaths referred to the MLDI system for which autopsies are not conducted (39). On the other hand, the percentage of unknown cause and manner of death was found to be as low as 0.015% among MLDI deaths that underwent forensic examination and autopsy, noting the value of a thorough examination in reaching conclusive cause and manner of death (40). In 1999, the Council of Europe developed a protocol on autopsies to be adopted by European states to provide more uniformity in autopsy practices and improve the MLDI death investigation process (33). Such guidance is beneficial to ensure deaths are properly investigated.

Criteria specifying cases for referral to the MLDI system and those requiring autopsy, noting physician authority in making this determination as well, are important legal framework considerations to ensure deaths are properly investigated and for the correct determination of cause and manner of death. These legal provisions or criteria are necessary but not sufficient in ensuring cases undergo the necessary investigation for determination of cause and manner of death. Mechanisms to monitor and ensure compliance are necessary as well. Studies in Taiwan, Sweden, Australia, and the United Kingdom found the under-reporting of reportable cases to the MLDI systems (35,41,42). Such oversight may result in the miscarriage of justice and also the under-reporting of certain injuries, thereby limiting the quality of cause of death data on unnatural deaths. As noted by Charles et al., the MLDI system in Australia, as in most other countries, is reliant on the referral of reportable deaths as it does not have the mechanism to search for reportable deaths itself (35). Physicians and other MLDI system stakeholders must be trained in the cases that require referral to the MLDI system to ensure that the appropriate cases are referred (41,42). In addition, procedures should be put in place to monitor referrals and the lack thereof in order to continuously improve the system.

Investigation Collaboration

Collaboration plays a critical role in the MLDI investigation process which can be quite complex with the engagement of various investigators, their roles, and responsibilities. A proper MLDI includes documentation of the scene and circumstances, because the ability of forensic pathologists to interpret autopsy findings depends on the context of the investigation (29,43). Therefore, forensic pathologists—regardless of the type of MLDI system they are working within—must have access to evidence of the scene and circumstances and should have the ability to request or direct some of the investigations, as needed, in order to get the information they rely on to interpret the cause and manner of death correctly. It is important that legal frameworks mandate cooperation between the investigating police and medical examiners, coroners, and/or forensic pathologists working in an enforcement-led system. In addition, the legal framework should grant these MLDI stakeholders certain specified powers to investigate, such as the authority to enter crime scenes secured by law enforcement, take control over the body, collect evidence relevant to the body, and subpoena relevant documents, such medical records (44).

South Africa has improved this area of its MLDI system by revising its MLDI legal framework to detail the participation of pathologists in the death investigation process. Prior to legal and system changes in 2006, the South African MLDI system was housed within the South African Police Service (SAPS). Investigation collaboration between SAPS and the forensic medical specialists was limited and, in some cases, the SAPS prohibited the release of information, thereby impacting medical investigations (36). Legal revisions in 2006 included language specifying the role of forensic medical specialists in the investigation process, which now enables investigation collaboration even as SAPS maintains jurisdiction of crime scenes. Stakeholder collaboration is a key element of any well-functioning MLDI system and should be presented in the law to support the necessary death investigation activities to improve the quality of cause and manner of death reporting in national vital statistics (16).

Amendment Process

Death investigations for cases referred to the MLDI system can be lengthy, as they entail additional review and testing that exceeds the standard process for completion and submission of MCCD forms to the registrar, often required within days of death (7,13). A study reviewing MCCD forms submitted in 2006 and 2007 by the Broward County medical examiner office in the State of Georgia (United States) found 3.37% of forms were amended, and most of these amendments were due to additional laboratory findings and medical history received after the initial medical certification and submission process (45). As noted in the UNSD Guidelines and GHAI Toolkit, amendments should be allowed to facilitate the inclusion of final determinations in cause and manner of death once the death investigation has concluded. As amendments may be required in other instances, that is, clerical errors, amendment provisions may be placed within broader CRVS laws rather than, or in addition to, MLDI laws.

A provision for amendment of cause and manner of death is necessary but not sufficient in ensuring revised cause and manner of death data are included in a country’s vital statistics. Until 2009, the MLDI reporting system in Spain did not include a process to incorporate the final determination of cause of death from autopsy results. In 2009, a cause of death data quality review of deaths referred to the MLDI system resulted in a process change, allowing the final autopsy results to be submitted to the register for deaths requiring inquests for possible revision of the cause of death. This change required collaboration among multiple MLDI system stakeholders, including the Public Health Agency of Barcelona, the Department of Health, and the Justice and Health Departments of the Government of Catalonia (13).

Tilhet-Coartet et al. called for this collaboration after a review of deaths in France in 1996 unveiled the under-reporting of violent deaths in national statistics by 30%. No homicides and only 22% of suicides that occurred in Lyon, France, were included in national statistics due to the failure of the MLDI cause of death reporting process to update and inform the national statistics office responsible for mortality statistics (7). The lack of coordination among agencies and their processes impacts the amendment process, which plays an essential role in the accurate and timely reporting of cause and manner of death (45).

Conclusion

The MLDI systems are complex due to system processes and the participation of various stakeholders. A strong MLDI system is underpinned by a well-founded legal framework grounded in international good practices. Given the evolution of various MLDI system types, a one-size-fits-all approach to legal framework recommendations will not provide the necessary guidance across all systems. The UNSD Guidelines and the GHAI Toolkit provide recommendations and guidance for stakeholder review of a country’s MLDI legal framework and good practice considerations for incorporation.

Legal framework improvements are a necessary starting point but are not sufficient in improving MLDI systems and the quality of cause of death data in national vital statistics systems. Efforts need to be made to ensure the system functions as defined by the law with monitoring mechanisms in place. Human resources development is critical to ensure physicians conduct MLDI death investigations according to best practices and correctly complete MCCD for accurate reporting of cause and manner of death. Stakeholder collaboration should be supported through clear presentation and regular review of stakeholder roles, responsibilities, and collaboration procedures. As complex systems, MLDI systems necessitate multipronged efforts for system strengthening and improving the quality of cause and manner death for public health action. Deficiencies in the functioning of MLDI systems have adverse impact on the quality and accuracy of vital statistics in both developing and developed countries.

ACKNOWLEDGMENTS

Chrystie Swiney and Erin Nichols for their review of the manuscript.

AUTHOR

Olga Joos DrPH, MPH, RN, CDC Foundation Inc

Roles: A, B, C, D, E, 1. Led the development and writing of the analysis.

Srdjan Mrkic, United Nations Statistics Division

Roles: B, C, D, 2. Participated in the writing of the analysis and provided critical feedback and edits to drafts.

Lynn Sferrazza JD, MSc, Legal Consultant/Global Health Advocacy Incubator

Roles: A, B, C, D, 2. Provided input into the development of the analysis, participated in the writing of the analysis, and provided critical feedback and edits to drafts.

Note

1.

In the context of this review article, a physician is a medical doctor trained in allopathic medicine.

Footnotes

DISCLOSURES & DECLARATION OF CONFLICTS OF INTEREST: The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest.

FINANCIAL DISCLOSURE: Bloomberg Philanthropies supported the contribution of Olga Joos and Lynn Sferrazza. Bloomberg Philanthropies did not exert any role in relation to the analysis or interpretations.

References

  • 1.United Nations Department of Economic and Social Affairs Statistics Division. Principles and Recommendations for a Vital Statistics System, Revision 3 [Internet]. United Nations publication; 2014: 224. Accessed June 24, 2021. https://unstats.un.org/unsd/demographic-social/Standards-and-Methods/files/Principles_and_Recommendations/CRVS/M19Rev3-E.pdf [Google Scholar]
  • 2.United Nations Legal Identity Expert Group. Implementation of the United Nations Legal Identity Agenda: United Nations Country Team Operational Guidelines [Internet]. United Nations Legal Identity Expert Group; 2020:67. Accessed June 24, 2021. https://unstats.un.org/legal-identity-agenda/documents/UNCT_Guidelines.pdf [Google Scholar]
  • 3.Mahapatra P, Shibuya K, Lopez A, et al. Civil registration systems and vital statistics: successes and missed opportunities. Lancet; 2007. DOI:10.1016/S0140- 6736(07)61308-7. Accessed June 24, 2021. [DOI] [PubMed] [Google Scholar]
  • 4.van de Walle E. Historical Development of Civil Registration Systems: A European Perspective. United Nations Department of Economic and Social Affairs; 2018:15. Technical Paper No.2018/1. [Google Scholar]
  • 5.World Health Organization. World Health Statistics 2020: Monitoring Health for the SDGs, Sustainable Development Goals [Internet]. World Health Organization; Published2020. Accessed June 24, 2021. https://apps.who.int/iris/bitstream/handle/10665/332070/9789240005105-eng.pdf [Google Scholar]
  • 6.World Health Organization. World Health Statistics 2019: Monitoring Health for the SDGs, Sustainable Development Goals [Internet]. World Health Organization; Published2019. Accessed June 24, 2021. https://apps.who.int/iris/bitstream/handle/10665/324835/9789241565707-eng.pdf [Google Scholar]
  • 7.Tilhet-Coartet S, Hatton F, Lopez C, et al. Importance des donnees medico-legales pour la statistique nationale des causes de deces. Presse Medicale. 2000;29(4):181–185. [PubMed] [Google Scholar]
  • 8.Guraraj G. Injury prevention and care: an important public health agenda for health, survival and safety of children. Indian J Pediatr. 2013;80(1):S100–S108. [DOI] [PubMed] [Google Scholar]
  • 9.Franca E, Campos D, Guimares MD, Souza MF. Use of verbal autopsy in a national health information system: effects of the investigation of ill-defined causes of death on proportional mortality due to injury in small municipalities in Brazil. Popul Health Metr. 2011;9(1):39. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Otieno G, Marinda E, Barnighausen T, Tanser F. High rates of homicide in a rural South African population (2000-2008): findings from a population-based cohort study. Popul Health Metr. 2015;13(1):20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.GBD 2016 Causes of Death Collaborators. Global, regional and national age-sex specific mortality for 264 causes of death, 1980-2016; a systematic analysis for the global burden of disease study 2016. Lancet. 2017;390(10100):1151–1210. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Iaych K, Khayesi M. Bold actions needed to improve civil registration data for road traffic deaths. Int J Contr Saf Promot. 2020;27(2):168–171. [DOI] [PubMed] [Google Scholar]
  • 13.Serra AP, Ramirez AF, Magarolas RG, et al. Deaths with medicolegal intervention and its impact on the cause-of-death statistics in Catalonia, Spain. Rev Esp Med Legal. 2017;43(1):13–19. [Google Scholar]
  • 14.Bhalla K, Harrison JE, Shahraz S, Fingerhut LA; Global Burden of Disease Injury Expert Group. Availability and quality of cause-of-death data for estimating the global burden of injuries. Bull World Health Organ. 2010;88:831–838C. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Hanzlick R. The conversion of coroner systems to medical examiner systems in the United States: a lull in the action. Am J Forensic Med Pathol. 2007;28:279–283. [DOI] [PubMed] [Google Scholar]
  • 16.Mavroforou A, Michalodimitrakis E. Forensic pathology on the threshold of the 21st century and the need for harmonization of current practice and training: The Greek concept. Am J Forensic Med Pathol. 2002;23(1):19–25. [DOI] [PubMed] [Google Scholar]
  • 17.Lucio P. Actualidad de la practica institucional forense en America central y panama. una opinion. Cuad Med Forense. 2012;18(2):49–53. [Google Scholar]
  • 18.Di Vella G, Campobasso CP. Death investigation and certification in Italy. Acad Forensic Pathol. 2015;5(3):454–461. [Google Scholar]
  • 19.Hanzlick R. A synoptic review of the 1954 model postmortem examination Act. Acad Forensic Pathol. 2014;4(4):451–454. [Google Scholar]
  • 20.United Nations Department of Economic and Social Affairs Statistics Division. Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management [Internet]. United Nations; Published2019:183. Accessed June 24, 2021. https://unstats.un.org/unsd/demographic-social/Standards-and-Methods/files/Handbooks/crvs/CRVS_GOLF_Final_Draft-E.pdf
  • 21.Global Health Advocacy Incubator. Civil Registration, Vital Statistics and Identity Management (CRVSID): Legal and Regulatory Review Toolkit [Internet]. Global Health Advocacy Incubator; Published2019: 191. Accessed June 24, 2021. https://advocacyincubator.org/wp-content/uploads/2020/12/CRVSID-Legal-and-Regulatory-Review-Toolkit.pdf [Google Scholar]
  • 22.Islam MN, Islam MN. Forensic medicine in Bangladesh. Legal Med. 2003;5:S357–S359. [DOI] [PubMed] [Google Scholar]
  • 23.Balachandra AT, Vadysinghe AN, William AL. Practice of forensic medicine and pathology in Sri Lanka. Arch Pathol Lab Med. 2011;135(2):187–190. [DOI] [PubMed] [Google Scholar]
  • 24.Cagdir S, Celbis O, Aydin NE, Soysal Z. Evolution of forensic autopsy and current legal procedures in Turkey. Am J Forensic Med Pathol. 2004;25(1):49–51. [DOI] [PubMed] [Google Scholar]
  • 25.Code of Criminal Procedure. India Code: Digital Repository of State Acts [Internet]. Published 1973. Accessed 24 June, 2021. https://www.indiacode.nic.in/handle/123456789/15247?view_type=browse&sam_handle=123456789/2510 [Google Scholar]
  • 26.World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, vol 2, Fifth Edition [Internet]. World Health Organization; 2016:841. Accessed June 24, 2021. [Google Scholar]
  • 27.Coroner Training Requirements [Internet] (2015). CDC. Accessed June 24, 2021. https://www.cdc.gov/phlp/publications/coroner/training.html [Google Scholar]
  • 28.Office of the United Nations High Commissioner for Human Rights. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Office of the United Nations High Commissioner for Human Rights; Professional Training Series No.8/Rev.1. 2004:76. [Google Scholar]
  • 29.Melinek J, Thomas LC, Oliver W, et al. National Association of the Medical Examiners Ad Hoc Committee on Medical Examiner Independence. National association of medical examiners position paper: medical examiner, coroner, and forensic pathologist independence. Acad Forensic Pathol. 2013;3(1):93–98. [Google Scholar]
  • 30.Chang S, Sterne JAC, Lu R, Gunnell D. Hidden suicides amongst deaths certified as undetermined intent, accident by pesticide poisoning and accident by suffocation in Taiwan. Soc Psychiat Epidemiol. 2010;45(2):143–152. [DOI] [PubMed] [Google Scholar]
  • 31.Walker S. Capturing health information—a coding perspective. Bull World Health Organ. 2006;84(3):254–255. [PMC free article] [PubMed] [Google Scholar]
  • 32.Lin C, Wang L, Lu T. Changes in drowning mortality rates and quality of reporting from 2004-2005 to 2014-2015: a comparative study of 61 countries. BMC Public Health. 2019;19(1):1391. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Brinkmann B. Harmonisation of medico-legal autopsy rules. Int J Legal Med. 1999;113:1–14. [DOI] [PubMed] [Google Scholar]
  • 34.Bimenya GS, Bhootra BL, Mukasa N. Forensic medicine services in Uganda—present and future. J Clin Forensic Med. 2005;12(2):81–84. [DOI] [PubMed] [Google Scholar]
  • 35.Charles A, Ranson D, Bohensky M, Ibrahim JE. Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne. Australia Int J Qual Health Care. 2007;19(4):232–236. [DOI] [PubMed] [Google Scholar]
  • 36.Saayman G.South Africa: vulnerable persons and groups in a vulnerable democracy—can forensic medical services help to ensure justice in critical times? 2017;7(3):434–443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Ylijoki-Sorensen S, Boldsen JL, Lalu K, et al. Cost-consequence analysis of cause of death investigation in Finland and in Denmark. Forensic Sci Int. 2014;245:133–142. [DOI] [PubMed] [Google Scholar]
  • 38.Ylijoki-Sorensen S, Boldsen JL, Boel LWT, et al. Autopsy rate in suicide is low among elderly in Denmark compared with Finland. Forensic Sci Int. 2014;244:158–165. [DOI] [PubMed] [Google Scholar]
  • 39.Nashelsky M, Lawrence C. Accuracy of cause of death determination without forensic autopsy examination. Am J Forensic Med Pathol. 2003;24(4):313–319. [DOI] [PubMed] [Google Scholar]
  • 40.George AA, Molina DK. The frequency of truly unknown/undetermined deaths: a review of 452 cases over a 5-year period. Am J Forensic Med Pathol. 2015;36(4):298–300. [DOI] [PubMed] [Google Scholar]
  • 41.Lu T, Shaw K, Hsu P, et al. Non-referral of unnatural deaths to coroners and non-reporting of unnatural deaths on death certificates in Taiwan: implications of using mortality data to monitor quality and safety in healthcare. Int J Qual Health Care. 2008;20(3):200–205. [DOI] [PubMed] [Google Scholar]
  • 42.Start RD, Delargy-Aziz Y, Dorries CP, et al. Clinicans and the coronial system: ability of clinicians to recognize reportable deaths. BMJ. 1993;306(6884):1038–1041. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Dolinak D, Matshes E, Lew E. Forensic Pathology: Principles and Practice. 1st ed. Academic Press; 2005. [Google Scholar]
  • 44.Weedn VW. Model medical examiner legislation. Acad Forensic Pathol. 2015;5(4):614–627. [Google Scholar]
  • 45.Fischtein D, Cina SJ. Errors on death certificates requiring amendments. Am J Forensic Med Pathol. 2011;32(2):146–148. [DOI] [PubMed] [Google Scholar]

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