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Comments:
•
The next most frequently cited causes of death were multiple organ failure, 11.2% (764); septicaemia, 11.1%
(757); pneumonia, 10.4% (709); and respiratory failure, 9.7% (664) in 6,836 conditions cited.
•
The most frequently cited cause of death was cardiac event, with 12.7% (866/6,836) of cases. In many cases this
reflects the terminal event and not the underlying pathology, and this has been identified as an issue in terms of
the accurate completion of death certificates.
(9-12)
The cardiac event category includes cardiac arrest, myocardial
infarction and cardiogenic shock. The next most frequently cited causes of death were multiple organ failure,
11.2% (764); septicaemia, 11.1% (757); pneumonia, 10.4% (709); and respiratory failure, 9.7% (664).
•
At times the cause of death is predictable as the existing comorbidities contribute to these as in a recent Australian
study that highlighted, “potentially modifiable comorbidities are associated with poorer postoperative outcomes”
(13)
•
The number of postmortems performed, including coronial requested postmortems, was 17% (1,052/6,179) of
cases. This rate remained constant during the full audit period and the reasons for the low rate of postmortem
referrals remain unknown. Postmortems were performed in 21.6% (206/951) of elective cases and 15%
(783/5,210) of emergency cases. It is known that postmortems are deemed to provide educational information and
valuable insights, and these referral rates are of concern.
(9-12)
•
The cause of death identified by the coroner’s office and by the VASM has identified a high degree of
concordance when the coronial diagnosis is used as the gold standard. A comparison of the VASM cause of death
analysis with coronial data clearly demonstrated that coronial data provides independent verification of VASM
data, even when a full internal postmortem examination has not been performed.
(14)