INACCURACY IN DEATH CERTIFICATION - WHERE ARE WE NOW

Background This review al-no document and analyse aspects of death cer tification that are relevant to public health. Methods A literature re view on death certification primarily used the computerized Index Medi cus (1981 to mid-1995), and concentrated on completing death certifica tes, accuracy, standards, education and procedural requirements. Furth er sentinel publications pre-dating this were identified from the main literature base. Results The uses of mortality data, historical and p rocedural context for recording death, the philosophy of Underlying Ca use of Death and its relationship to 'the truth', the extent and impac t of 'inaccuracy', the certificate and the certifier, and possible way s forward are discussed. It is argued that the question 'How inaccurat e are cause of death data?' is harder to answer than the literature su ggests, Deriving a useful estimate is difficult because of inter-study differences in (1) definition, measurement (how and by whom?) and pra ctical importance of error, and standards used; (2) focus (e.g. death certificate or mortality data), observing everyday practice or simulat ion exercises, diagnostic and/or semantic issues. Conclusion The tradi tional perspective on improving the quality of death certification has not worked. There is a need for reorientated thinking rather than jus t urging more education. Evidence-based educational interventions are needed. The flaws in the theoretical framework of cause of death and t he routine nature of death certification are unavoidable, but require consideration. Certifiers need practical feedback mechanisms, integral to continuing quality assurance tall levels and fostering an understa nding of the construction of mortality data. Continued development sho uld be a core public health medicine role.