Certification of CAUSE and MANNER of
(NOTE: you are now on Dr. Ervin Shaw's personal
The S. C. death certificate PROCESS.
Facts, explanations, and opinions come from
evidence and witnesses and are considered routinely in arriving at the cause and manner of
death. Most such determinations are expeditiously made outside of any court of law, though
always within some legal jurisdiction.
A "fact...or ordinary...witness" is generally not
allowed to state opinions or
conclusions about facts of a case in a court of law. An "expert witness," however, upon
being recognized by the court (the judge) as an expert, is expected to give facts and draw
conclusions or state opinions. An "expert witness" is anyone the judge will
allow as an expert.
Cause of Death:
The CAUSE of a person's death
is...in the final analysis...a medical determination or finding based on evidence and
opinion. The cause may be considered over several time frames: the original or underlying
(proximate) cause; intermediate or intervening causes; and immediate (or dependent)
For example, a 48 year old woman has a breast lump
removed; following a number of years, the cancer re-appears in her bones; chemotherapy
follows. She later dies with pneumonia. Breast cancer is the underlying or proximate cause of
death and pneumonia is the immediate or dependent cause of death.
And scientists might also be interested in the
biological mechanism (probably either hypoxia or a fatal arrhythmia) of the
"proximate cause" becomes a different thing when applied to civil lawsuits for medical malpractice.
The South Carolina Medical Association handbook, "Physicians Guide to Malpractice Law in South
Carolina" [updated March 2000, pages 59-70) indicates that the legal definition of "proximate
cause" in medical malpractice is one of the trickiest legal definitions in law. In medical
malpractice, proximate cause of death or injury to plaintiff is more like the "dependant cause" of
death certification. It is the event (or lack of, or failure of an event or action) that
"but for" the fact that it happened or failed to happen, the injury or death would
never have happened [the "responsible cause"]. Also, in the malpractice arena, expert testimony is
usually required to pinpoint (assign or fix) the "proximate cause"; and the winning of a case by
plaintiff usually requires 3 interconnected
- (1) plaintiff must
have actually suffered damages or injury (or death);
- (2) defendant
physician (health-care worker) performance or nonperformance is
- (3) the
interconnection between the first two is explained to the jury's satisfaction by the "proximate
- and, the "most
probable standard" indicates that plaintiff must introduce evidence that the injuries
complained of "most probably" [greater than 50% probability] resulted from the alleged
- and, negligence need
not be the sole cause of an injury...it can be sufficient for the alleged negligence to be a
"proximate concurring cause" or a "contributing cause".
- and, though it might
be established that a physician's conduct, or lack thereof, has in fact been one of the causes
of the patient's injuries, the defendant is not necessarily liable in the absence of
"foresee-ability". A defendant cannot be condemned for that which cannot be foreseen, is
unpredictable, and could not be expected to happen.
- and, some states
have adopted a "loss of chance doctrine" ["increased risk of harm doctrine"] whereby the
defendant can be held liable if his conduct increased the risk of harm to the patient
Amazingly, even after a
thorough autopsy, the cause of death may be uncertain or "unascertained". Most are comfortable with
the designation of SIDS (sudden infant death syndrome) in infants. Society finds it difficult to
accept inability to determine an exact cause of death at an age beyond infancy. But, I can
personally attest that these are not rare situations (the "obscure death autopsy" rate is published
as no less than 5% of autopsies).
The MANNER of a person's death
is...in the final analysis...a legal determination or finding based on evidence and opinion.
It is usually routinely assigned, but it is always subject to dispute/challenge and might not
come to a truly finalized assignment until decided after thorough discovery & disclosure
of all case facts in a court of law after all appeals are exhausted. That is, if someone
wants to contest a manner of death, it is ultimately decided in a court of law...court
actions tending to drag along slowly. Outside of court proceedings, such findings are legally
made by government-employed or elected medical examiners or coroners. Medical opinions or
conclusions obtained during the case investigation are usually given great weight, whether
from general doctors or pathologists trained in (and practicing) forensic pathology (remember
the TV program, Quincy)? In our fast-paced society, decisive information (not yet put
forward) is sometimes absent at the time that the manner of death opinion is by a coroner or
medical examiner. Manner of death can have immense importance in whether people undergo
intense personal investigation, go to jail, receive large lawsuit awards, or receive multiple
(double or triple indemnity) payments on life insurance policies.
There are five categories of manner of
manner of death: the death is purely a consequence of one or a combination of natural
>accidental manner of death: unintended and essentially unavoidable death,
not by a natural, suicidal or homicidal manner [also see
>accidental manner of death because of
failure of supervision: This mostly applies to children (small child drowns as
the parents are distracted). This might also include adults with known or unknown underlying
health problems who either knowingly "push the limit" or "push the limit", ignorant of the
>accidental manner of death because impulsive suicidal
display/threat gone bad: a gang member young male in a verbal battle with his mother
brandishes his loaded and cocked pistol against his own head as he tries to get his own way. In
the excitement and tension of the situation, the pistol accidentally is set off and kills
>accidental manner of death because sham suicide went
bad: a distraught young man who was unable to get a job returned home to live with his
parents. Wanting to be able to live without responsibility, a long-running conflict had
developed between him and the parents. Hoping to gain sympathy and get his way long term, he
set up a rope and noose in his closet and slipped it around his neck as he sat on a stool and
pretended unconsciousness, hoping to set up a sham suicide that would shock his parents into
yielding to his demands. But, somehow, the stool tipped over. Before, he could loosen the
strangling noose, he blacked out and slumped enough to fatally tighten the choke hold of the
>homicidal manner of
by good deed: if one human is
responsible for the death of another but in an involuntary way & without legally negligent
behavior, the death may be legally called "involuntary manslaughter". Were you in the
right-hand lane of a 4-lane road & were to wave a driver waiting at a parking lot exit to
come across in front of your stopped lane and the driver's intent (known or unknown) was to
LEFT turn and he/she gets T-boned & killed by an unseen moving driver in the other
lane on your side, you MAY be guilty of involuntary manslaughter (though society may not yet be
ready to label it as such)!
by sustaining sympathetic
attention: an episode (30 May 2011, "The Unreal World") of the TV series, Body of
Proof, is about the mother of a girl with a disease requiring treatment. Mom substituted sugar
pills for the real medicine to keep daughter sick so that Mom would not lose the constant
sympathy that she craved from her circle of friends. The daughter dies, having other
complicating disease, too.
suicidal: Death caused by self,
with some degree of conscious intent. A permanent solution to what could be a temporary
problem! One should always be very skeptical on hearing of a multi-injury death (multiple
gunshot wounds; multiple stab wounds) being ruled as a suicidal manner of death [FA09-40]!
While Munchausen syndrome deaths
are self-caused by the deceased, society does not...by convention...count these as suicidal.
There are a few recognized instances of secret set-ups for suicidal death by another (such
as suicide by cop); and there are others less conventionally recognized types of suicidal
degrees of recklessly indifferent risky behavior (FA11-110; also drunken speeding death of
Jackass member Ryan Dunn June 2011). Society also does not count self-caused deaths as
suicide (1) due to calculated (society sometimes even celebrating such deaths when happening
under celebrated & advertised challenges) deaths in high risk activities (remember lucky
Evel Knievel but not-so-fortunate Mt. Everest climbers?), (2) ignorant (alcohol binge
drinking) & reckless behavior as one often sees among teenagers, (3) poor lifestyle
habits, or (4) known self-destructive habits...when the deceased unequivocally knew that
he/she was putting his/her life in danger. And, homicides can be made to look like a suicide
(faked suicide [see CBS's 48 Hours episode about 2008 of a Baptist preacher faking his
wife's suicide) or an accident (faked accident).
homicidal: death caused by
another human [check out types &
degrees] in a (1) conscious way & to now include (2) such
unconscious &/or mentally ill or deranged way as Munchausen by proxy deaths or include cases where the killer was in a frantic "survival mode",
essentially unconscious acts which result in the death of another.
- undetermined: not enough evidence, yet or ever, to choose
the manner of death.
- unclassified: too complex to classify; it either stays in
that category or has to be clarified and declared legally with action in a coroner system or
medical examiner system or rarely in a court of law.
Some Manner-of-Death Conventions
(1) By common convention/custom,
an unavoidable killing of another person by a sober person responsibly going
about his/her business is considered to be an accidental manner of death...not homicide.
Sadly, too often the declaration of "unavoidable" is made too quickly because of the
human-nature discomfort over the distress of the killer and his/her family (who are still
alive). My partner, Dr. John Carter, and I (he has discovered, defined, and best articulated
the problem with this common convention; and I agree) think that any and all deaths should
undergo a thorough, essentially check-listed investigation, hammering at the issue of
avoidability. Example: auto-pedestrian deaths...(1) what is the evidence for or against
"visibility" (was location such that intense sunlight was in the driver's eyes...and was the
windshield visor up or down?) (2) was there any posted sign declaring a pedestrian crossing?
(3) was a car phone in the vehicle? If so, what was the exact time of calls about the time of
the killing? (4) what was the emotional state of the killer and of the deceased just prior to
the killing event...the sobriety of each? (5) what human distractions were available to
killer and deceased (driver distracted by crying infant?)...deceased distracted by an ongoing
argument? We have seen at least one instance where the driver was alcohol-intoxicated and the
sober lover switched & claimed to be the driver prior to arrival of anyone else on the
scene. When Dr. Carter assigned "homicide" as the manner of death, the stories quickly
changed and the case clarified. As you can imagine, it could take some real questioning
investigation...even lie detector testing...to truly settle the question of
"Crib death" or SIDS (sudden infant death
syndrome) cases are especially delicate. When a baby or infant is found dead sleeping in the
bed with other older persons, the issue of "avoidable death" is problematic. Were the others
in the bed knowledgeable of such as "death by overlying" or were they ignorant? Were they
sober...if not, it may be a homicide [FA08-23]?
(2) By common
convention/custom, an accidental killing of oneself is an accidental manner of death...not
(3) By nearly common convention/custom, those found
dead of a disease or abnormality known to be associated with unexpected sudden death [see listing] are declared dead by natural manner
unless [a] complicated by an obvious accidental component (then reasonably declared an accidental
manner of death) or [b] death happening during an abduction (homicide).
For example #1, epileptics may
be found dead...an accepted, though sad and disappointing outcome. If found face down in the
pillow, one might propose asphyxia as the proximate cause = accidental manner of death. But such
asphyxia in an adult (as opposed to an infant) is more of a speculation; most would certify the
manner as natural (possibly...not surely...proximately asphyxiating). But, an epileptic found dead
in the bath-tub, head submerged, would be certified as accidental manner (probably...essentially
For example #2, a 60+ year old man [FA10-160] has become determined to lose weight and decides to do it by working out in the heat of the day and/or in the gym and at home and sweating the weight off. The autopsy was without evidence of disease. An arrhythmogenic electrolyte abnormality...accidentally induced by extreme exercise to sweat weight off was left as the presumed cause of death...making it an accidental death. The above examples assume autopsy absence of medication overdose
& failure to detect other over-riding causes or manners.
Autopsies often provide critical
information in determination of THE TRUTH of the cause and manner of
enforcement agencies, coroner's staff, or those in the medical examiner's office...only "knows"
what it finds out (or what comes to light) by the point in time when preliminary, updated, or
"final" determinations of cause and manner of death need to be made. Depending on a large number of
factors, the urgency and pressure to "finalize" a case can vary from intense to mild. Though it may
require legal action to do so, it is always possible to attempt a change in cause or manner of
death based on new information. Barring any apparent controversy or high-profile factors in a case,
deaths which appear to have straightforward cause and manner are fairly quickly classified as what
they appear to be. With or without postmortem or autopsy exam or other special tests or procedures,
the classification is...simply...whatever the medical examiner or coroner says it is.
The system may need your help!
If you have clear information which might have a
bearing on the correct determination of cause & manner of death in a case...especially if
you have reason to believe that a miscarriage of justice has happened or is
happening...contact the coroner's office or medical examiner's office having
jurisdiction over the case.
Should you find yourself in the situation of a
victim, in that you are sure of a miscarriage of justice and don't seem to be able to get
anywhere, victims assistance programs may help you wedge into the system and correct a wrong
or otherwise seek justice. My friend, Laura Hudson, is a founding visionary of such
***give me your comments about this
check out the Highest
(posted 29 July 1998; latest addition 14 May 2014)