Pathology and Certification of Natural and Violent Deaths
Certification requires you to state a cause, mechanism, and manner that are internally consistent and legally defensible. Know the standard sequence: immediate cause, antecedent conditions, and the underlying cause that initiated the fatal sequence, plus contributing conditions. Manner categories are natural, accident, suicide, homicide, undetermined, and pending.
Key concepts: the cause of death is the disease or injury, the mechanism is the physiologic derangement (e.g., exsanguination, arrhythmia), and the manner is the circumstances. Traps include writing a mechanism as the cause ("cardiac arrhythmia" alone), calling a death homicide when the manner is actually accident (a fall during a fight), and misclassifying a drug overdose. Intent matters: a self-inflicted gunshot wound is suicide, an unintentional overdose is accident, and an overdose with unclear intent may be undetermined. Sudden infant death syndrome is a diagnosis of exclusion requiring scene and history review. Deaths in custody, restraint asphyxia, and excited delirium require careful documentation.
Worked example
A man with cirrhosis dies of bleeding esophageal varices after a fall that did not cause injury. Cause: exsanguination from ruptured esophageal varices due to cirrhosis. Manner: natural. The fall is incidental. Rule of thumb: the underlying cause must be the condition without which the death would not have occurred; if that condition is natural, the manner is natural even with a coincidental event.
Document scene, history, toxicology, and autopsy findings before certifying, especially in undetermined cases.