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This is a combination of CQI and Istat Questionnaire

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					                                            Results for Part I
                                         ANAMORT QUESTIONNAIRE
                                            Summary results
                                             January 2008




"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
                                                         The ANAMORT
                                                      Steering committee
                                                    PARTNERS OF THE PROJECT

* Belanger, François                                              *Gjertsen, Finn
Head of the ANAMORT Project                                       Norwegian Institute of Public Health
InVS-Institut de Veille Sanitaire                                 Division of Epidemiology
Unité Traumatismes - DMCT                                         Marcus Thranes gate6
14 rue du Val d'Osne                                              P.O. Box 4404 Nydalen
94415 Saint Maurice Cedex – France                                NO-0403 Oslo - Norway
email: f.belanger@invs.sante.fr                                   email: Finn.Gjertsen@fhi.no
* Bene, Monika
Hungarian Central Statistical Office                              * Jougla, Eric
H-1024 Budapest                                                   Inserm-CépiDc, Institut National de la Santé et de la
Population Statistics Department                                  Recherche Médicale
Keleti Károly u. 5-7 - Hungary                                    44 chemin de ronde
email: Monika.bene@ksh.hu                                         78116 Le Vesinet, - France
* Bruzzone, Sylvia                                                email: jougla@vesinet.inserm.fr
Direzione centrale per le statistiche e le indagini sulle         * Nectoux, Marc
istituzioni sociali (Italy)                                       Psytel - Université Paris 5
Servizio Sanita e Assistenza                                      Direction des sytèmes d'information (SGIR)
Via Liegi 13                                                      45 rue des Saints Pères
00198 Roma - Italy                                                75270 PARIS Cedex 06 - France
email: bruzzone@istat.it                                          email: nectoux@dsi.univ-paris5.fr
* Denissov, Gleb                                                  * Steiner Monica
The Statistical Office of Estonia                                 Kuratorium für Verkehrssicherheit
Endla 15                                                          Bereich Heim, Freizeit & Sport
EE-15174 Tallinn - Estonia                                        Schleiergasse 18
email: Gleb.denissov@stat.ee                                      A-1100 Vienna - Austria
* England, Kathleen                                               email : monica.steiner@kfv.at
Department of Health Information                                  * Thélot, Bertrand
95 Guardamangia Hill                                              Chief of the Trauma Unit
Guardamangia MSD 08 - Malta                                       InVS-Institut de Veille Sanitaire
email: kathleen.grima@gov.mt                                      Unité Traumatismes - DMCT
* Falzon, Aygul                                                   14 rue du Val d'Osne
ANAMORT Project                                                   94415 Saint Maurice Cedex – France
InVS-Institut de Veille Sanitaire                                 email: b.thelot@invs.sante.fr
Unité Traumatismes - DMCT                                         * Ung, Aymeric B.
14 rue du Val d'Osne                                              ANAMORT Project
94415 Saint Maurice Cedex – France                                InVS-Institut de Veille Sanitaire
email: a.falzon@invs.sante.fr                                     Unité Traumatismes - DMCT
* Frimodt-Møller, Birthe                                          14 rue du Val d'Osne
National Institute of Public Health                               94415 Saint Maurice Cedex – France
25 Svanemøllevej                                                  email: a.ung@invs.sante.fr
DK-2100 Copenhagen Ø - Denmark
email: bfm@niph.dk

This is the summary of the results of a questionnaire filled in during the 1st quarter of 2006 by the experts of
the following 38 countries/regions : Albania; Austria, Bosnia and Herzegovina, Belgium, Bulgaria,
Switzerland, Serbia and Montenegro, Cyprus, Czech Republic, Germany, Denmark, Estonia, Spain, Finland,
France, Greece , Croatia, Hungary, Ireland, Iceland, Italy, Lithuania, Luxembourg, Latvia, Macedonia, The
Former Yugoslav Republic of, Malta, Netherlands, Norway, Poland, Portugal, Romania, Sweden, Slovenia,
Slovak Republic, Turkey, United Kingdom (UK) England and Wales, UK - Scotland, UK – Northern Ireland


ANAMORT PROJECT
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Chapter A/ General information
A9/ What is your position in your department? (Persons who have completed the questionnaire)
Head of department or equivalent                 10
Researcher/Statistician/Adviser                  23
Other                                            5        Project manager; State expert; Chief specialist
                                                          Medical officer; Team leader
A10/ Indicate the location of the office producing statistics on causes of death in your country?
Ministry of Health                               2
National Statistical Institute                   28
Other                                            5
Several locations                                3
A11/ Do you belong to the office producing statistics on causes of death?
Yes                                              34
No                                               4
A12/ Are you involved in the analysis of mortality data?
Yes                                              37
No                                               1
Chapter B/ Death certificate and certification (in
general)
B1/ Evolution of the medical part of the death certificate (from 1990 to 2005)
Number of lines available in part I (underlying cause of death) of the death certificate
1 line in 1990 and 1 line in 2005                1
2 lines in 1990 and 2 lines in 2005              1
2 lines in 1990 and 4 lines in 2005              3
3 lines in 1990 and 3 lines in 2005              20
3 lines in 1990 and 4 lines in 2005              8
4 lines in 1990 and 4 lines in 2005              4
8 lines in 1990 and 8 lines in 2005              1
Existence of a part II (other medical condition)
Yes in 1990 and Yes in 2005                      34
No in 1990 and Yes in 2005                       1
No in 1990 and No in 2005                        3
Existence of a printed arrow (representing the causal chain)
Yes in 1990 and Yes in 2005                      5
No in 1990 and Yes in 2005                       4
No in 1990 and No in 2005                        29
Existence of question mentioning an autopsy was done
Yes in 1990 and Yes in 2005                      27
No in 1990 and Yes in 2005                       3
Yes in 1990 and No in 2005                       1        (Yes in 2007)
No in 1990 and No in 2005                        7
B1/ Evolution of the medical part of the death certificate (from 1990 to 2005) [continued]
Existence of free-text field describing circumstances of injury or poisoning
Yes in 1990 and Yes in 2005                      25
No in 1990 and Yes in 2005                       1
No in 1990 and No in 2005                        12
Existence or revision of guidelines for certifier attached to each death certificate
Yes in 1990 and Yes in 2005                      16
No in 1990 and Yes in 2005                       3
No in 1990 and No in 2005                        19
B2/ When did (will) your country introduce a death certificate specific for infants (including a part on
medical causes of death)?
1979 or before                                   3
ANAMORT PROJECT January 2008                                                                         Page 3 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Between 1980 and 1989                            3
Since 1990                                       6
Introduced but year unknown                      6
Not available until now and not planned          20
B3/ If there is an infant death certificate, what age range does it cover? (18 countries concerned)
From 22 weeks of gestation to 1 day                          1
From 22 weeks of gestation to 6 days                         1
From 22 weeks of gestation to 7 days                         2
From 22 weeks of gestation to 27 days                        2
From 22 weeks of gestation to 28 days                        1
From 24 weeks of gestation (or weight=500 g or length=30 cm) to 6 days              1
From 24 weeks of gestation to 10 days                        1
After a certain duration of gestation (perinatal period) to 6 days 1
After a certain duration of gestation (prenatal death) to 7 days 1
After a certain duration of gestation (different definitions between the civil code and WHO) to 364 days 1
After a certain duration of gestation to 365 days            1
From delivery (even if not alive) to 6 days                  1
From delivery (even if not alive) to 7 days                  1
From live birth to 27 days                                   2
From live birth to 364 days                                  2
B4/ If there is an infant death certificate in your country, how are the causes of death presented? (18
countries concerned)
Two parts: one for maternal                      7
One part,                                        7
Other presentation                               2
Unknown                                          0
No response                                      2
B5/ Who are the persons authorised to certify the causes of death in your country (at hospital or
otherwise)?
Head of the service physician in hospital
Never                                            4
Sometimes                                        22
Often                                            5
Always                                           6
No response/Unknown                              1
B5/ Who are the persons authorised to certify the causes of death in your country (at hospital or
otherwise)? [continued]
Medical student in hospital
Never                                            35
Sometimes                                        1
Often                                            1
Always                                           0
No response/Unknown                              1
Junior physician in hospital
Never                                            10
Sometimes                                        17
Often                                            5
Always                                           4
No response/Unknown                              2
Physician in charge of the deceased (in hospital or otherwise)
Never                                            0
Sometimes                                        5
Often                                            17
Always                                           16
ANAMORT PROJECT January 2008                                                                         Page 4 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
No response/Unknown                              0
Coroner
Never                                            23
Sometimes                                        6
Often                                            1
Always                                           7
No response/Unknown                              1
B5/ Who are the persons authorised to certify the causes of death in your country (at hospital or
otherwise)? [continued]
Pathologist
Never               7
Sometimes           14
Often                                            7
Always                                           9
No response/Unknown                              1
General practitioner
Never                                            3
Sometimes                                        8
Often 16
Always                                           11
No response/Unknown                              0
Emergency specialist
Never                                            6
Sometimes     18
Often                                            8
Always                                           6
No response/Unknown                              0
Legal doctor
Never                                            5
Sometimes                                        15
Often                                            5
Always                                           12
No response/Unknown                              1
B5/ Who are the persons authorised to certify the causes of death in your country (at hospital or
otherwise)? [continued]
Other physicians (than those listed above)
Never                                            6
Sometimes     19
Often                                            6
Always                                           5
No response/Unknown                              2
Non medical staff
Never                                            34
Sometimes                                        2
Often                                            1
Always                                           0
No response/Unknown                              1
B6/ Do you record on the death certificate the qualification (as mentioned in the previous question) of
the death certifier?
No, it is not possible                           14
It is possible but rarely used                   9
It is possible and used                          7
It is possible and systematically used           8
Unknown                                          0
ANAMORT PROJECT January 2008                                                                         Page 5 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
B7/ Do certifiers directly enter the ICD codes for the causes of death in your country?
Yes              7
No               31
B8/ Do you record on the death certificate that the death certifier is the treating physician (or that he
has taken care of the patient before his/her death, i.e. the certifier knows the patient’s history)?
No, it is not possible                             16
It is possible but rarely used                     10
It is possible and used                            5
It is possible and systematically used             6
Unknown                                            0
No response                                        1
treating physician unless the death is certified by the coroner)
B9/ What other data are available in the final individual mortality file?
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Country of data collection
Yes but no source                                 1
Death certificate                                 16
National statistical office                       6
Office in charge for official demographic         4
        statistics/population registry
Census                                            0
Other sources                                     1
More than one source                              5
Not available                                     5
Unknown                                           0
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Unique case identification number
Yes but no source                                 0
Death certificate                                 14
National statistical office                       5
Office in charge for official demographic         5
        statistics/population registry
Census                                            0
Other sources                                     1
More than one source                              6
Not available                                     6
Unknown                                           0
No response                                       1
Location at death (region/ department or city)
Yes but no source                                 0
Death certificate                                 24
National statistical office                       3
Office in charge for official demographic         2
        statistics/population registry
Census                                            0
Other sources                                     1
More than one source                              6
Not available                                     0
Unknown                                           0
No response                                       2
B9/ What other data are available in the final individual mortality file? [continued]
ANAMORT PROJECT January 2008                                                                         Page 6 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Place of death (hospital, home, street, work, public area…)
Yes but no source                                0
Death certificate                                26
National statistical office                      3
Office in charge for official demographic        1
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             5
Not available                                    2
Unknown                                          0
Sex
Yes but no source                                0
Death certificate                                26
National statistical office                      2
Office in charge for official demographic        3
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             6
Not available                                    0
Unknown                                          0
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Date of birth (or age at death)
Yes but no source                                0
Death certificate                                25
National statistical office                      2        I
Office in charge for official demographic        4
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             6
Not available                                    0
Unknown                                          0
Date of death
Yes but no source                                0
Death certificate                                27
National statistical office                      2
Office in charge for official demographic        2
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             6
Not available                                    0
Unknown                                          0
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Race/ethnicity
Yes but no source                                0
ANAMORT PROJECT January 2008                                                                         Page 7 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Death certificate                                4
National statistical office                      3
Office in charge for official demographic        2
        statistics/population registry
Census                                           0
Other sources                                    0
More than one source                             2
Not available                                    25
Unknown                                          2
Nationality
Yes but no source                                0
Death certificate                                18
National statistical office                      3
Office in charge for official demographic        5
        statistics/population registry
Census                                           1
Other sources                                    0
More than one source                             1
Not available                                    10
Unknown                                          0

B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Country of residence
Yes but no source                                0
Death certificate                                20
National statistical office                               3
Office in charge for official demographic        6
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             3
Not available                                    4
Unknown                                          0
No response                                      1

Place of residence (region, department or city)
Yes but no source                                0
Death certificate                                23
National statistical office                      2
Office in charge for official demographic        6
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             6
Not available                                    0
Unknown                                          0
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Profession of the deceased person
Yes but no source                                0
Death certificate                                14
ANAMORT PROJECT January 2008                                                                         Page 8 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
National statistical office                      5
Office in charge for official demographic        2
        statistics/population registry
Census                                           2
Other sources                                    0
More than one source                             3
Not available                                    11
Unknown                                          0
No response                                      1
Usual occupation
Yes but no source                                0
Death certificate                                10
National statistical office                      5
Office in charge for official demographic        1
        statistics/population registry
Census                                           1
Other sources                                    1
More than one source                             0
Not available                                    19
Unknown                                          0
No response                                      1
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Employment situation of the deceased or of the legal guardian
Yes but no source                                0
Death certificate                                8
National statistical office                      6
Office in charge for official demographic        0
        statistics/population registry
Census                                           1
Other sources                                    1
More than one source                             1
Not available                                    20
Unknown                                          0
No response                                      1
Education level
Yes but no source                                0
Death certificate                                10
National statistical office                      6
Office in charge for official demographic        2
        statistics/population registry
Census                                           0
Other sources                                    1
More than one source                             2
Not available                                    16
Unknown                                          0
No response                                      1
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Type of injury (intentional/ non-intentional)
Yes but no source                                0
Death certificate                                27
ANAMORT PROJECT January 2008                                                                         Page 9 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
National statistical office                      2
Office in charge for official demographic        1
statistics/population registry
Census                                           0
Other sources                                    2
More than one source                             4
Not available                                    2
Unknown                                          0
Pregnancy state
Yes but no source                                0
Death certificate                                11
National statistical office                      1
Office in charge for official demographic        0
        statistics/population registry
Census                                           0
Other sources                                    3
More than one source                             1
Not available                                    20
Unknown                                          1
No response                                      1
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Occupational disease
Yes but no source                                0
Death certificate                                5
National statistical office                      0
Office in charge for official demographic        0
        statistics/population registry
Census                                           0
Other sources                                    5
More than one source                             2
Not available                                    25
Unknown                                          0
No response                                      1
Recent surgery
Yes but no source                                0
Death certificate                                10
National statistical office                      0
Office in charge for official demographic        0
        statistics/population registry
Census                                           0
Other sources                                    2
More than one source                             2
Not available                                    23
Unknown                                          0
No response                                      1
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Alcohol use
Yes but no source                                0
Death certificate                                7
National statistical office                      0
ANAMORT PROJECT January 2008                                                                         Page 10 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Office in charge for official demographic        0
        statistics/population registry
Census                                           0
Other sources                                    2
More than one source                             3
Not available                                    25
Unknown                                          0
No response                                      1
Illegal drugs use
Yes but no source                                0
Death certificate                                8
National statistical office                      0
Office in charge for official demographic        0
        statistics/population registry
Census                                           0
Other sources                                    2
More than one source                             4
Not available                                    23
Unknown                                          0
No response                                      1
B9/ What other data are available in the final individual mortality file? [continued]
You can consider as ”available”, any information included in the mortality file or that can be linked with the
mortality file
Other items
                 Time (hour) of death, place of accident, date and time (hour) of accident, number of deaths in the
                 commune death register, civil status, date of birth of surviving husband or wife, date of last marriage,
                 living situation, marital status, age of spouse, birth weight for deaths under 1 year of age, age in hours
                 for deaths within 24 hours, place of accident, name and surname of the deceased have been contained in
                 the mortality data base for a record linkage with other sources, such as demographic surveys, name of
                 declaring physician, number of the cause of death in the death register, legitimate or natural child aged
                 less than 5 years, hospital discharge


Chapter C/ Death certificate and certification (concerning death due to
external causes of injury and poisoning: ESSL 58-65 and ICD-10 S00 -Y98)
C1/ Are there complementary investigations made in case of non-natural deaths in your country?
Never                                            2
Sometimes/Always                                 36
Unknown                                          0

C2/ If sometimes/always, specify in which situations (36 countries concerned)
Ill-defined and unknown causes of mortality
Sometimes                                        18
Always                                           15
Unknown                                          3
Unexplained sudden deaths
Sometimes                                        18
Always                                           17
Unknown                                          1
Unknown causes of death
Sometimes                                        17
Always                                           17
Unknown                                          2
Injuries, poisonings and certain other consequences of external causes
ANAMORT PROJECT January 2008                                                                         Page 11 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Sometimes                                        15
Always                                           20
Unknown                                          1
C1/ Are there complementary investigations made in case of non-natural deaths in your country?
[continued]
External causes of mortality
Sometimes                                        16
Always                                           19
Unknown                                          1
Accidents
Sometimes                                        18
Always                                           17
Unknown                                          1
Intentional self-harms
Sometimes                                        12
Always                                           23
Unknown                                          1
Assaults
Sometimes                                        8
Always                                           27
Unknown                                          1
Events of undetermined intent
Sometimes                                        13
Always                                           21
Unknown                                          2
C1/ Are there complementary investigations made in case of non-natural deaths in your country?
[continued]
Legal interventions and operations of war
Sometimes                                        7
Always                                           24
Unknown                                          3
No response                                      2
Complications of medical and surgical care
Sometimes                                        25
Always                                           9
Unknown                                          2
Other causes of death (when specified)
                 Infant deaths, accidental falls, AIDS

C3A/ If yes to any of the above questions, specify the situation and the type of investigation (36
countries concerned)
              Legal medicine, criminal police, emergency medical care.
              Autopsy by law, by requirements from physician, court, police, family.
              Investigation by the police and the judicial (legal) authorities should always follow a non-natural death.
              Autopsy, chemical and/or microscopical examination of tissues will be done on request of the judicial
              investigator (juge d'instruction). If the judicial authorities decide that the case is not to be persecuted
              (accidental fall, suicide, traffic accident, etc.), further investigation (i.e. autopsy) can still be done on
              request of the treating physician or on request of the family. If there is no judicial (legal) request, the
              family needs to give its permission.
              The rules for conducting police investigation as well as legal and medical expertise are defined in the Code
              of Penal Procedure.
              In case of exceptional death, legal doctor has to be called.
              It is usually full post-mortem examination ordered by the Court of law along with police investigation of
              the case.
ANAMORT PROJECT January 2008                                                                         Page 12 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
             For all the above situations, the investigations include police inquests, coroner inquests, autopsies,
             biochemical and fluid analysis, blood tests for alcohol and other substances.
             Autopsy, police investigation, toxicology.
             In case of suspicion of an external cause of death: Autopsy.
             Forensic / Pathological autopsy
             Legal intervention and more information required (legal autopsy).
             By the law (1973/948): Forensic autopsy with investigations for clarifying the cause of death and police
             investigation.
             Medico legal obstacle
             The medical examiner makes an autopsy.
        C3A/ If yes to any of the above questions, specify the situation and the type of investigation
           [continued]
             According to our Health Act, coroners (coroners are medical doctors or health workers) who are suspecting
             that death is a consequence of a criminal fact, inform the police and magistrate. They are then starting with
             complementary investigation. We obtain the results of these investigations if we query our colleague from
             the County Institute of Public Health who are working on supplementation of data on Death Certification.
             The investigation has to be carried out by the police and it is obligatory in almost all of the above
             mentioned cases.
             Coroner performs post-mortem, and if necessary, holds an inquest.
             Deaths reported to police, extents of investigation (enquiries, forensic autopsies, etc) are their decision.
             Back to the Municipality Civil Status Officer and Certifier.
             Autopsy, toxicological investigation
             Press for road accidents. Autopsy is asked for all perinatal death but we do not always received results of
             the autopsy made by the pathologist.
             Violence against neonates by parents.
             Autopsies made in a hospital in cases of: Unexplained sudden deaths, Unknown causes
             Legal autopsies in cases of: Injuries, poisonings and certain other consequences of external causes,
             External causes of mortality, Accidents, Intentional self-harms, Assaults, Events of undetermined intent
             In cases of Complications of medical and surgical care, it can be both.
             In cases of external causes of death, autopsy is carried out in most cases. Usually supplemented by
             toxicology and histology. In sudden or unexplained deaths not due to external causes of death, especially in
             the elderly, autopsy may not be carried out. When a person died of natural cause and there is no suspicion
             of foul play.
             Police, legal autopsy, Board of Health investigation, military investigation.
             Most of them are done by the Ministry of Justice and we do not have the results.
             Autopsy
             Police report, forensic autopsy (falls and fractures in the elderly are generally not investigated).
             Autopsy, toxicology in most cases, not in very old persons sometimes. In doubtful cases also investigating
             magistrate is involved.
             Autopsy and autopsy certificate - If autopsy was made, basic results are filled in a special box for autopsy
             results (Part I - 3 lines Part II - 1 line Part III - 1 line for description of causes of death included in XIX
             chapter of ICD-10 by V01-Y98 (XX chapter)).
             Police investigate these non-natural deaths and autopsy is made by the doctor of Ministry of Justice
             Council of Forensic Medicine. But it is not known, this situation is done for all non-natural deaths or not.
             The death forms are always filled in with the solution of autopsy.
             Coroner's inquest and/or police investigations. The only type of injury/accident which may not receive a
             complementary investigation is a death from a fall in an elderly person.
             Referred to procurator fiscal who carries out an investigation involving medical and legal aspects.
             Coroner
C3B/ Do you obtain the results of these investigations? (36 countries concerned)
Never                                            1
Sometimes                                        23
Always                                           12
Unknown                                          0

ANAMORT PROJECT January 2008                                                                         Page 13 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
C4/ On average, what is the median time between death and recovery of the results of the investigation
or inquiry? (35 countries concerned)
Less than 6 months                               20
6 to 11 months                                   11       1 country wrote: 6 to 11 months for judicial (legal)
                                                          investigations
12 to 23 months                                  2
More than 24 months                              1
Unknown                                          1
C5/ Are there official criteria available for the certifier in your country to define death as a suicide?
Yes                                              8
No                                               23
Unknown                                          7
C6/ If Yes, specify definition applied (8 countries concerned)
The medical examiners define death as a suicide according to the International criteria in bibliography e.g. Cameron,
  Simpson etc.
CDC definition
Definition used in ICD-10: Injury without/with intention. If intention, certifiers have to select between suicide,
  homicide and other types of intentional injury.
The definition is identical with WHO.
It depends on the knowledge of medical practitioner. Specialists on forensic medicine are fairly aware of conditions that
  have to be fulfilled in case of suicide. As far as I know the criteria applied in Slovenia are the same as defined in CDC
  definition.
In the cases of suicide and homicide, a legal autopsy has to be made (according to a special law).
It is up to individual coroner, but the requirement in law is that the deceased intended to kill themselves beyond
  reasonable doubt - i.e. the same burden of proof for a conviction for murder in a criminal court.
C7/ In the case of external causes of injury and poisoning in death, is the role of alcohol consumption
recorded on the death certificate?
Not at all/never                                 5
Rarely                                           8
Occasionally                                     19
Frequently                                       4
Always/systematically for all deaths             2
Unknown                                          0
C8/ When toxicological analyses are performed, what is the approximate proportion of certificates that
are coded using the toxicological results?
<1% (never)                                      6
1-9% (rarely)                                    4
10-33% (sometimes)                               2
34-50% (often)                                   2
51-66% (most of the time)                        2
67-89% (frequently)                              0
90-99% (very frequently)                         5
>99% (always)                                    8
Unknown                                          9
C9/ When a firearm is involved in the death, what is the approximate proportion of death certificates
that mention it?
<1% (never)                                      3
1-9% (rarely)                                    0
10-33% (sometimes)                               0
34-50% (often)                                   1
51-66% (most of the time)                        0
67-89% (frequently)                              3
90-99% (very frequently)                         10

ANAMORT PROJECT January 2008                                                                         Page 14 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
>99% (always)                                    16

Unknown                                          5
C10/ Is it possible to identify the role of family violence from the death certificate related to injury and
poisoning?
Never                                            21

Sometimes                                        13
Always                                           1
Unknown                                          3
C11/ In the death certificate, is it possible to identify the place where injury causing death related to
injury and poisoning occurred?
Never                                            6
Sometimes                                        22
Always                                           10
Unknown                                          0
C12/ Is it possible to identify the activity at the time of injury on your death certificate related to injury
and poisoning?
Never                                            9
Sometimes                                        24
Always                                           5
Unknown                                          0
C13/ In death certificates you receive, is there information on the succession of events and factors that
led to the injury or poisoning?
Never                                            13
Sometimes                                        20
Always                                           5
Unknown                                          0
C14/ Is there any rule that lead to a systematic investigation in case of non-natural or external causes of
injury and poisoning related deaths?
Done by the police?
Yes                                              31
No                                               6
Unknown                                          1
C14/ Is there any rule that lead to a systematic investigation in case of non-natural or external causes of
injury and poisoning related deaths? [continued]
Done by a pathologist?
Yes                                              29
No                                               8
Unknown                                          1
Done by a magistrate?
Yes                                              16
No                                               18
Unknown                                          3
No response                                      1
Done by other persons/institutions?
Yes       14    Coroner, certifying doctor. Forensic specialist. External causes are investigated by a multidisciplinary
          team constituted by police, pathologists, criminologists, magistrates, etc. Medical examiner. Coroner. A doctor
          is always involved, if not the forensic pathologist, then another doctor performing an examination with the
          police on site. Forensic medicine examiner – expert. Can be special investigation carried out by different
          inspection authorities. Medical doctor who certifies death can decide if systematic investigation performed by
          the police, forensic medicine or magistrate is needed. Legal doctor. Military Police. Coroner. Investigation by
          procurator fiscal. Coroner
No                                               10
ANAMORT PROJECT January 2008                                                                         Page 15 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Unknown                                          8
No response                                      6
C14/ Is there any rule that lead to a systematic investigation in case of non-natural or external causes of
injury and poisoning related deaths? [continued]
If Yes to one or more, approximately in what proportion can you take the results into account for
codification? (37 countries concerned)
<1% (never)                                      5
1-9% (rarely)                                    0
10-33% (sometimes)                               1
34-50% (often)                                   0
51-66% (most of the time)                        2
67-89% (frequently)                              7
90-99% (very frequently)                         9
>99% (always)                                    8
Unknown                                          5
Chapter D/ Guidelines (attached to each death certificate) and training for
certifiers
D1A/ Are there guidelines for certifiers included in your current death certificate?
Yes                                              22
No                                               16
Unknown                                          0
D1B/ If Yes, what do they include? (22 countries concerned)
Examples                                         1
Text without examples                            7
Text with examples                               11
Other type                                       0
Both                                             2
Other                                            1
Unknown                                          0
D2/ Do you think that guidelines in use for death certifiers in your country need to be improved?
Yes                                              30


No                                               5
Unknown                                          2

No response                                      1
D3/ If Yes, what should be improved in guidelines for death certifiers? (30 countries concerned)
ICD-10
Exact description of process coding with examples.
Examples
After the first year of the implementation of the Xth Revision in 2005, the analysis of data quality and comparability
                 should be the used for revision.
They are very detailed. So we would like to write a leaflet with examples.
Not specified
The guidelines should be developed according to the Manual on Certification of Causes of Death.
There should be better additional guidelines (e.g. manual) for physicians on how to certificate causes of death, because
                 information included on death certificate is insufficient.
D3/ If Yes, what should be improved in guidelines for death certifiers? [continued]
The definition and importance of the lines and the underlying cause must be clearer.
Greater emphasis on explaining the concept of underlying cause of death.
More details
To have compact guide about the most important things with examples.
ANAMORT PROJECT January 2008                                                                         Page 16 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Electronic interactive help.
Better training of certifiers in University.
It should be improved recording of type of injury, primarily location of neoplasm and data about pregnancy in time of
  death.
Better presentation of most important guidelines.
They should be made more accessible to certifiers, perhaps by attaching them to the certificate or with access via
  internet.
A translation of EU manual and web based training tool is currently developed.
Adjustment to the ICD-10.
Training is needed both pre and post medical school as well as training leaflets and occasional reminders and questions
  about particular death certificates. Presently nothing exists in Malta.
More examples, including examples how not to fill in, better accessibility and more arguments/explanations why data
  are needed in this way.
Improve guidelines for part I and II, and the need for manner of intent if injury. Information about place and activity for
  injury.
Text with examples.
The examples from the Guidelines should be added.
The guidelines are to be more precise and should eliminate the risk of interpret the guidelines wrongly.
Definitions of particular (underlying or immediate) causes of death must be revised and be written more clearly on
  death certificate. Possibly it would be helpful to add the arrow and role out its meaning.
To establish a centre for e-learning and consulting potential problems via PC-net.
After revising the death certificate of Turkey, especially we should make guidelines for causes of death part of death
  certification.
Different instructions for doctors and coroners.
Development of web-based guidelines (possibly based on EU training package).
D4/ Since 2003, has training of medical students on death certification been modified?
Yes, in terms of duration                        1
Yes, in terms of content                         2
Yes duration and content                         1
No                                               28       In 1 country, there is no complete medicine degree course (only
                                                 first two years). All students are trained in foreign countries.
Unknown                                          6
D4/ If Yes specify (4 countries concerned)
Due to the merging of the Xth Revision with the IXth.
We are not in charge of this training.
Since autumn 2005, medical students get one extra hour on explanation of the death certificate, it is about different parts
 and how to fill it in (so now they get 3 hours tutoring on the subject).
Implementation of the project Improvement of statistics on the causes of death (MTF 2004 EUROSTAT).
D5/ Are physicians trained to fill in the death certificate?
Yes, systematically as part of their             17
mandatory continuous medical education
Yes, on a voluntary basis                        9        In 1 country, the training will be included into the
                                                          mandatory medical education from 2007
No                                               9
Unknown                                          3
D6/ Have you adapted the tool to your country (translation, contacts, specific organization...)?
Leaflet on death certification (2 pages explaining the main rules for death certification)
Yes                                              10
No                                               27
Unknown                                          1
Manual on certification of causes of death in Europe
Yes                                              5
No                                               32
Unknown                                          1

ANAMORT PROJECT January 2008                                                                         Page 17 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Web Based training tool for physicians
Yes                                              0
No                                               37
Unknown                                          1
D7/ If Yes, how did you disseminate it?
Leaflet on death certification (10 countries concerned)
No dissemination has been done                   1
Usual post for all physicians                    2
During continuous medical education              0
Other                                            4      Civil registers. The main rules are planned to take use as
                instructions for certifiers in update of the leaflet made by authorities. Directly by medical health
                officers. Posted when querying physicians.
Several responses                                2
Unknown                                          0
Manual on certification of causes of death in Europe (5 countries concerned)
No dissemination has been done                   1
Usual post for all physicians                    0
During continuous medical education              0
Other                                            3
Unknown                                          0
Several responses                                1

Web Based training tool for physicians (none country concerned)
D8/ Which modifications did you made before diffusion?
Leaflet on death certification (9 countries concerned)
We have not done modifications.
Shortened
Translation in Greek language
Information on drug related deaths and changes in cause of death after toxicology was added. Items which are not
                included on national death certificate were excluded.
The information of the leaflet is taken by adapting it to Finnish circumstances.
Section of “How to add specificity?” was rewrote and enlarged.
Changed layout less detailed.
Adaptation to natinal death certificate.
Translation, adaptation under existing legislation (insignificant modification).
Manual on certification of causes of death in Europe (4 countries concerned)
Shortened
Translation in Greek language.
Chapter on perinatal deaths, special certification problems, some case histories deleted.
Translation
Web Based training tool for physicians (none country concerned)
D9/ If No, why?
Leaflet on death certification (27 countries concerned)
The Leaflet on death certification is not adapted with new rules of mortality coding. The main reason is lack of capacity
  in the State Agency for Statistics of BIH established recently.
Lack of coordination (coordinator died in December 2004), defederalised subject.
Not specified
In Switzerland, mortality statistics exist since 1876. Our certificate of cause of death is "traditionally" the other way
  round and was never adapted to the international one: we begin with the underlying cause of death under Ia and have
  only one other line Ib for the disease/condition leading directly to death. So we have to transform all the guidelines to
  Swiss conditions. There were never enough resources to adapt them all.
We did not receive any new tools for death certification.
We created our own leaflet, which is available for free.
Lack of resources. A leaflet modified to reflect the introduction of the electronic death certificate is planned.
ANAMORT PROJECT January 2008                                                                         Page 18 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Need to be translated.
Because of time
Because we have just been informed about the tool.
In May 2006, Ministry of Health started with the Project of education of coroners who fill in death certificates. We have
  also planed to modify our current DC and to make Manual for certification of causes of death. This is an issue that the
  Statistical Office referred to the medical authorities.
We did not have financial resources for translating and publishing training material. It is planned to adapt and publish
  the Leaflet on death certification within the framework of the 2004 Transition Facility project "Improvement of
  statistics of causes of death".
It is planned but not done yet.
It is already in process.
Financial difficulties and time
No priority
Capacity
Not specified
D9/ If No, why? [continued]
Leaflet on death certification [continued]
We are currently adapting.
We actually use for the death diagnosis the rules from the International Statistical Classification of Diseases and Related
 Health Problems, Tenth Revision. We translated, together with the Institute of National Statistics, the Manual for
 Certifying the Death Causes in Europe, EUROSTAT-ISTAT (Rome, December 2003). A number of 90 family
 physicians were trained and we follow experimentally the application of the manual rules without cancelling the rules
 mentioned earlier that are official.
The instructions given on the death certificate contains more or less the same information.
At that time, the content of a leaflet had not been prepared yet, but now within the framework of EU: Transition Facility
 PHARE 2004 Project No.5.6 Causes of Death, the content of the leaflet is prepared and is ready for technical design
 and publishing, that will be followed by distribution to medical examiners (coroners) filling in the death certificates.
So far, the Ministry of Health has not co-operated with the Statistical Office in order to improve data quality. However,
 in 2006-2007, we will join the project “Improvement of statistics of causes of death” and we hope the situation will
 change.
We have not applied this leaflet yet.
Already had version suitable for use needing no local modifications. Therefore easier with limited resources to update
 this one.
New instructions were prepared in 1999.
Manual on certification of causes of death in Europe (32 countries concerned)
Replacement of the nomenclature of causes of death from ICD-9 to ICD-10.
The Manual on certification of causes of death in Europe is not adapted with new rules of mortality coding. The main
  reason is lack of capacity in the State Agency for Statistics of BIH established recently.
Lack of coordination, defederalised subject, responsibility of regional ministries of education, translation going on.
The implementation of the ICD-10 has started in 2005. The implementation of the Manual on certification of causes of
  death in Europe is a basic aim of the ongoing PHARE 2004 project. The project will end in November 2007.
Lack of resources
We did not receive any new tools for death certification.
The adaptation of Manual has been prepared since this year (within the framework of Transition Facility program
  2004). For the past months, we used the manual as a base for preparation of training material which will be used in
  training of post gradual students and adapted version of which will be distributed as a "Core information on COD" to
  selected certifiers (physicians) and put on the relevant website. We plan to adapt the whole manual as well and to
  distribute it via website during the next year.
Under the responsibility of the general medical council of each Federal state.
Lack of resources. A version modified to reflect the introduction of the electronic death certificate is planned.
Need to be translated.
We made a training material (certifica) that includes manuals.
The language problems and resource problems
It depends on the Ministry of Health.

ANAMORT PROJECT January 2008                                                                         Page 19 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
In May 2006, Ministry of Health started with the Project of education of coroners who fill in death certificates. We have
  also planed to modify our current DC and to make Manual for certification of causes of death. I have also found it on
  the web side. We plan to use the manual.
D9/ If No, why? [continued]
Manual on certification of causes of death in Europe [continued]
Other priorities
This is an issue that the Statistical Office referred to the medical authorities.
The translation of the manual is in preparation.
We did not have financial resources for translating and publishing training material. It is planned to adapt and publish
                  the Manual on certification within the framework of the 2004 Transition Facility project "Improvement
                  of statistics of causes of death".
It has to be discussed.
It is already in process.
Time issue
No priority
Capacity
Not specified
We have already done a small book before. However, the manual seems to be better used by university students.
We actually use for the death diagnosis the rules from the International Statistical Classification of Diseases and Related
  Health Problems, Tenth Revision. We translated, together with the Institute of National Statistics, the Manual for
  Certifying the Death Causes in Europe, EUROSTAT-ISTAT (Rome, December 2003). A number of 60 family
  physicians from Bucharest and 30 from Ploiesti were trained and we follow experimentally the application of the
  manual rules without cancelling the rules mentioned earlier that are official.
Too massive for routine use, but would be useful as a reference.
For the Manual there was the same timetable as for the leaflet. The Manual is now translated and adapted. It can be
  distributed in printed version, not yet published version, to the same users as was answered on a previous question.
Not specified
We have not applied this manual yet.
Already had version suitable for use needing no local modifications. Therefore easier with limited resources to update
  this one.
May be considered if resources permit.
Web Based training tool for physicians (37 countries concerned)
Online-learning tool is planned in cooperation with the chamber of doctors.
The main reason is lack of capacity in the State Agency for Statistics of BIH recently established.
Translation not planned yet.
The implementation of the web based training tool is not planned.
Lack of resources
We have never heard of the Project mentioned above.
We are not certain if this tool needs to be translated for the time being. We shall make a decision on this matter in the
 future. Most physicians are able to read medical English.
The adaptation of web tool is planned, but not done yet.
Under the responsibility of the general medical council of each Federal state.
Lack of resources. A version modified to reflect the introduction of the electronic death certificate is planned.
No funds
Certifica is also a training tool. In Spain, we use a web based tool, developed by the Ministry of Health, which fulfils
 the WHO recommendations and the national legislation. This tool includes training material.
The language problems and resource problems.
We use a specific website for electronic death certification to offer the physicians different helps on certification. This
 site also allows making training for death certificates.
Because we had no answer from the responsible Ministry.
Unfortunately, we do not have possibility to use web training tool for physicians.
Due to lack of manpower at the moment.
Other priorities
This is an issue that the Statistical Office referred to the medical authorities.

ANAMORT PROJECT January 2008                                                                         Page 20 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
The adaptation of the Italian version is in preparation but we are going to disseminate this product within 2 years (lack
  of resources).
We did not have possibilities to disseminate the Web based tool. It is planned that in 2007
It has to be discussed.
In the future, during continuous medical education, after translation and adaptation of website.
We still make preparations.
Time issue
No priority
Capacity
It is difficult to use the programme since it is based on a death certificate that is different from the one we use.
We are going to adapt it after assessing the actual experiment, thus being able to be applied in 2008.
Lack of time
Web based tool has not been used yet because at the Institute of Public Health, there is not enough human resources to
  prepare it for use. We will do it if new staffs come. In the meantime, we are going to work using the Manual, the
  Leaflet and the Power Point presentation.
Not specified
We have not applied this manual yet.
No resources available to adapt for use, particularly with respect to local laws.
To be considered if resources permit.
D10/ Do you plan to do it?
Leaflet on death certification (27 countries concerned)
Yes                                              16
No                                               5
Unknown                                          4
No response                                      2
Manual on certification of causes of death in Europe (32 countries concerned)
Yes                                              19
No                                               7
Unknown                                          6
Web Based training tool for physicians (37 countries concerned)
Yes                                              18
No                                               9
Unknown                                          9
No response                                      1
D11/ Have you identified or anticipated difficulties for its adaptation?
Yes financial difficulties                       5
Yes technical difficulties                       5
Both                                             9
No difficulties identified until now             8
Unknown                                          9
No response                                      2
Chapter E/ Codification rules and application
E1/ ICD classifications used for coding the causes of death in 2006
ICD-10                                           34       From 1994       3
                                                          From 1995       3
                                                          From 1996       6
                                                          From 1997       5
                                                          From 1998       5
                                                          From 1999       2
                                                          From 2000       2
                                                          From 2001       2
                                                          From 2002       2
                                                          From 2003       1
                                                          From 2004       1
ANAMORT PROJECT January 2008                                                                         Page 21 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
                                                          From 2005     1
                                                          From 2006     1
ICD-9                                                 3   ICD-10 planned in 2007 in 1 country
ICD-8                                            1        ICD-10 planned in 2009
E2/ Are you familiar with the regular WHO updating process of ICD-10?
Yes I have heard of it                           16
Yes I am familiar with it                        22
No, I have never heard of it                     0
Unknown                                          0
E3/ Have you applied any ICD-10 classification updates since its implementation? (34 countries
concerned)
Yes, all of them                                 11
Yes, some of them                                9
No but we plan to do it                          3
No and we do not plan to do it/                  8
No and we do not know if we plan to do it
Unknown                                          2
No response                                      1
E3/ Have you applied any ICD-10 classification updates since its implementation? [continued]
If Yes, which ICD-10 classification update(s) have you applied? (20 countries concerned)
1996 revision applied since:
1996                                             3
1998                                             2
1999                                             1
2000                                             1
2002                                             2
2003                                             2
2004                                             2
2005                                             1
2006                                             1
Not applied yet                                  1
No response                                      4
1997 revision applied since:
1997                                             2
1998                                             2
1999                                             1
2000                                             1
2002                                             2
2003                                             2
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  1
No response                                      4
1998 revision applied since:
1998                                             4
1999                                             1
2000                                             1
2002                                             2
2003                                             2
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  1
ANAMORT PROJECT January 2008                                                                         Page 22 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
No response                                      4
1999 revision applied since:
1999                                             5
2000                                             1
2002                                             2
2003                                             2
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  1
No response                                      4
E3/ Have you applied any ICD-10 classification updates since its implementation? [continued]
If Yes, which ICD-10 classification update(s) have you applied? [continued]
2000 revision applied since:
2000                                             6
2001                                             1
2002                                             2
2003                                             2
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  1
No response                                      3
2001 revision applied since:
1999                                             1
2001                                             6
2002                                             3
2003                                             2
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  1
No response                                      2
2002 revision applied since:
2002                                             6
2003                                             2
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  4
No response                                      3
2003 revision applied since:
2001                                             1
2003                                             9
2004                                             2
2005                                             2
2006                                             1
Not applied yet                                  2
Unknown                                          1
No response                                      2
E3/ Have you applied any ICD-10 classification updates since its implementation? [continued]
If Yes, which ICD-10 classification update(s) have you applied? [continued]
2004 revision applied since:
2004                                             9

ANAMORT PROJECT January 2008                                                                         Page 23 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
2005                                             1
2006                                             3
Not applied yet                                  4
Unknown                                          1
No response                                      2
2005 revision applied since:
2003                                             1
2005                                             9
2006                                             2
Not applied yet                                  6
Unknown                                          1
No response                                      1
E4/ If you do not use or plan to use one or more ICD-10 updates, explain briefly why (11 countries concerned)
It depends on available capacity.
The implementation of new revisions as well as the applied version are decided and specified in the Ordinance of the
    Minister of Health.
Planned in 2007 with the implementation of the second edition of ICD-10 classification that takes into account all
    updates from 1996 to 2003 versions.
We do not plan to use ICD updates
We will start using updates in 2006.
Priority on continuity.
Coding rules have been changed after ICD-10 implementation, but not systematically according to official updates and
    implementation dates (changes have been documented and are available on internet).
We have heard about them only.
Not specified
Application of the updates should be in the interest of the Ministry of Health of the Slovak Republic.
E5/ Are you able to use the 4th digit (after the dot) to select the underlying cause of death?
Not at all/never                                 3
Rarely                                           1
Occasionally                                     0
Frequently                                       5
Always/systematically                            29
Unknown                                          0
E6/ If your answer to the previous question was different from “not at all/never” or
“Always/systematically”, specify in which situation you are using the 4th digit (6 countries concerned)
It is not an obligation to use 4th digit and it once depends on death certifier.
When information is available.
Mainly, some exceptions (the 4th digit in accidents is compensated by crossing of the alternatives:
  transport/work/sport/free time/home/health care unit/other).
In most of the cases, we use it, but there are a lot of “9” as 4th digit in our database due to poor certification practice,
  especially for transport accidents, accidental falls and poisonings.
It depends on the information provided on the death certificate.
Our programme has to have 4 digits, and if we have good death certificate, we could use the 4th digit.
E7/ In the causes of death database, are the injury related deaths coded according to the same
classification (ICDx) as all deaths?
Yes                                              37


No                                               1
Unknown                                          0
E8/ If no, specify which classification do you use for injury related death (1 country concerned)
TR                Not specified
E9/ Do you think it is important to collect information about autopsies in the death certificate such as:
Autopsy done
Yes                                              36
No                                                                                 1
ANAMORT PROJECT January 2008                                                                         Page 24 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Unknown                                          1
Legal autopsy done
Yes                                              29


No                                               6
Unknown                                          3
E9/ Do you think it is important to collect information about autopsies in the death certificate such as:
[continued]
Autopsy made in a hospital
Yes                                              25
No                                               11
Unknown                                          2
Autopsy used for certification
Yes                                              34
No                                               3
Unknown                                          1
E10/ When an autopsy is done are the results used for the coding?
Not at all/never                                 0
Rarely                                           2
Occasionally                                     6
Frequently                                       9
Always/systematically                            21
Unknown                                          0
E11/ When a legal autopsy is done, is the office o
Not at all/never                                 3
Rarely                                           4
Occasionally                                     4
Frequently                                       7
Always/systematically                            20
Unknown                                          0
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.)
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL28: Mental and behavioural disorders
Include ICD-10 codes F00-F99, ICD-9 codes 290-319, ICD-8 codes 290-315
0% (never)                                       2
<1% (very rarely)                                11
1-9% (rarely)                                    9
10-33% (sometimes)                               3
34-50% (often)                                   1
51-66% (most of the time)                        0
67-89% (frequently)                              0
90-99% (very frequently)                         1
>99% (always)                                    0
Unknown                                          11
Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (25 countries concerned)
Self-injuries
Falls, injuries, poisoning and certain other consequences of external causes (chapter XIX). These cases represent 1.5%
                  of all F codes in the mortality file.
Falls, Suicides
ANAMORT PROJECT January 2008                                                                         Page 25 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Poisonings
Suicides
Suffocations, falls
"Foreign body in respiratory tract" (ICD-10 code: T17).
Falls coded as epilepsy
Accidental poisonings
In all types
Almost all codes of external causes of mortality (i.e. transport accidents, falls, drownings, suicides, assaults)
Suicides, homicides and accidental poisonings (about 3% in 2001/02-data).
If it is mentioned on a death certificate. In most cases, it is mentioned with suicides.
Acute poisonings
Drug poisonings (accidental and undetermined)
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 29: Alcohol abuse (including alcoholic psychosis)
Include ICD-10 code F10, ICD-9 codes 291 and 303, ICD-8 codes 291 and 303
0% (never)                                        3
<1% (very rarely)                                 7
1-9% (rarely)                                     10
10-33% (sometimes)                                0
34-50% (often)                                    2
51-66% (most of the time)                         0
67-89% (frequently)                               0
90-99% (very frequently)                          1
>99% (always)                                     0
Unknown                                           15
Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (20 countries concerned)
Suicides, self-injuries, injuries and certain other consequences of external causes (chapter XIX).
Traffic Accidents
Poisonings
 “Foreign body in respiratory tract” (ICD-10 code: T17).
E860 (Accidental poisoning by alcohol). NB: this external cause will be recorded also.
In all types
Almost all codes of external causes of mortality (i.e. transport accidents, falls, drownings, suicides, assaults).
Suicides, homicides and accidental poisonings (about 2% in 2001/02-data).
Only if acute intoxication with alcohol is the underlying cause death otherwise if toxicology is done.
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 30: Drug dependence, toxicomania
Include ICD-10 codes F11-F16 and F18-F19, ICD-9 codes 304-305, ICD-8 codes 304-305
0% (never)                                        4
<1% (very rarely)                                 8
1-9% (rarely)                                     8
10-33% (sometimes)                                2
34-50% (often)                                    1
51-66% (most of the time)                         0
67-89% (frequently)                               0
ANAMORT PROJECT January 2008                                                                          Page 26 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
90-99% (very frequently)                         3
>99% (always)                                    0
Unknown                                          12
Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (22 countries concerned)
Suicides, accidents, assaults
Suicides, self-injuries
Suicides, falls, injuries and certain other consequences of external causes (chapter XIX).
Traffic Accidents
Poisonings
Poisonings by drugs
This cause could hide an overdose death (considered as external death).
Accidental poisonings by drugs
In all types
Almost all codes of external causes of mortality (i.e. transport accidents, falls, drownings, suicides, assaults).
Suicides, homicides and accidental poisonings (about 2% in 2001/02-data).
Acute poisonings
Drug poisonings (accidental and undetermined) - to be changed in the near future following WHO guidance to stop
                  using F11 code as underlying cause.
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 33: Diseases of the circulatory system
Include ICD-10 codes I00-I99, ICD-9 codes 390-459, ICD-8 codes 390-444.1, 444.3-458 and 782.4
0% (never)                                       4
<1% (very rarely)                                7
1-9% (rarely)                                    9
10-33% (sometimes)                               1
34-50% (often)                                   0
51-66% (most of the time)                        2
67-89% (frequently)                              0
90-99% (very frequently)                         0
>99% (always)                                    0
Unknown                                          15

Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (19 countries concerned)
Assaults, suicides, accidental poisonings (in older ages).
Transport accidents, injuries, poisoning and certain other consequences of external causes (chapter XIX). These cases
                  represent 2.8% of all I codes in the mortality file.
Craniocerebral injuries
All categories
Falls, drownings, traffic accidents.
Falls, traffic accidents
Falls (Fracture of femur)
Accidents where effect of trauma is not easily visible (falls, blunt head trauma for example). Domestic violence could
                  fall under here as in so many similar categories.
For instance, pulmonary embolism instead of fall and femoral fracture.
Maybe in the elderly related to accidental falls.
Suicides, homicides and accidental poisonings (about 2% in 2001/02-data).


ANAMORT PROJECT January 2008                                                                         Page 27 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 37: Diseases of the respiratory system
Include ICD-10 codes J00-J99, ICD-9 codes 460-519, ICD-8 codes 460-519
0% (never)                                       6
<1% (very rarely)                                6
1-9% (rarely)                                    8
10-33% (sometimes)                               1
34-50% (often)                                   0
51-66% (most of the time)                        0
67-89% (frequently)                              0
90-99% (very frequently)                         0
>99% (always)                                    0
Unknown                                          17

Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (15 countries concerned)
injury, poisoning and certain other consequences of external causes (chapter XIX). These cases represent 2.2% of all J
                 codes in the mortality file.
Cerebrovascular accidents, inhalation of vomiting, asphyxia, fracture of hip
All categories
Falls (Fracture of femur)
Accidents where effect of trauma is not easily visible (falls, blunt head trauma for example). Domestic violence could
                 fall under here as in so many similar categories.
Environmental factors, threats to breathing, poisonings
Maybe in the elderly related to accidental falls.
Suicides, homicides and accidental poisonings (about 2% in 2001/02-data).

E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 42: Diseases of the digestive system
Include ICD-10 codes K00-K93, ICD-9 codes 520-579, ICD-8 codes 520-577 and 444.2
0% (never)                                       4
<1% (very rarely)                                11
1-9% (rarely)                                    7
10-33% (sometimes)                               0
34-50% (often)                                   0
51-66% (most of the time)                        0
67-89% (frequently)                              0
90-99% (very frequently)                         0
>99% (always)                                    0
Unknown                                          16
Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (18 countries concerned)
Accidental poisonings
Injury, poisoning and certain other consequences of external causes (chapter XIX). These cases represent 7.1% of all
                K00-K93 codes in the mortality file.
ANAMORT PROJECT January 2008                                                                         Page 28 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Asphyxias
Drownings from food consumption.
“Foreign body in respiratory tract” (ICD-10 code: T17).
Accidents where effect of trauma is not easily visible (falls, blunt head trauma for example). Domestic violence could
               fall under here as in so many similar categories.
Maybe poisonings (adhesions after having a chemical substance).
Suicides, homicides and accidental poisonings (about 3% in 2001/02-data).
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 48: Diseases of the genitourinary system
Include ICD-10 codes N00-N99, ICD-9 codes 580-629, ICD-8 codes 580-629 and 792
0% (never)                                       8
<1% (very rarely)                                8
1-9% (rarely)                                    6
10-33% (sometimes)                               0
34-50% (often)                                   0
51-66% (most of the time)                        0
67-89% (frequently)                              0
90-99% (very frequently)                         0
>99% (always)                                    0
Unknown                                          16

Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (14 countries concerned)
For2005 data: injury, poisoning and certain other consequences of external causes (chapter XIX). These cases represent
                 4.6% of all N codes in the mortality file.
Falls (fracture of femur)
Accidents where effect of trauma is not easily visible (falls, blunt head trauma for example). Domestic violence could
                 fall under here as in so many similar categories.
Pyelonephritis after traumatic stricture.
Suicides, homicides and accidental poisonings (about 2-3% in 2001/02-data).
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 55: Symptoms, signs, abnormal findings, ill-defined causes
Include ICD-10 codes R00-R99, ICD-9 codes 780-799, ICD-8 codes 780-782.3, 782.5-791 and 793-796
0% (never)                                       3
<1% (very rarely)                                6
1-9% (rarely)                                    10
10-33% (sometimes)                               4
34-50% (often)                                   0
51-66% (most of the time)                        0
67-89% (frequently)                              0
90-99% (very frequently)                         0
>99% (always)                                    0
Unknown                                          15
Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (20 countries concerned)
ANAMORT PROJECT January 2008                                                                         Page 29 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
All injury related deaths except transport accidents.
For2005 data: intentional self-harm by unspecified means (X84) and unspecified event, undetermined intent (Y34).
                  These cases represent 1.5% of all R codes in the mortality file.
Falls (Fracture of hip)
All categories
Cases after toxicological examination that are impossible to define or other cases from septicaemia (ICD-9 codes 799.9,
                  799.1).
All deaths related to late consequences of trauma (immobility).
Accidents where effect of trauma is not easily visible (falls, blunt head trauma for example). Domestic violence could
                  fall under here as in so many similar categories. This is the category of diagnoses where instances
                  would be assigned where a doctor issues a certificate without having a specific cause of death but the
                  police would not see reason to ask for a forensic examination (as the rules are here in Iceland).
Poisonings
Suicides, falls, poisonings
Assaults coded in senility (R54).
E.g. if body is decomposed.
Suicides, homicides and accidents (about 3-5% in 2001/02-data).
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 57: Unknown and unspecified causes
Include ICD-10 codes R96-R99, ICD-9 codes 798.1-9,799, ICD-8 codes 795.2-796
0% (never)                                       4
<1% (very rarely)                                7
1-9% (rarely)                                    6
10-33% (sometimes)                               5
34-50% (often)                                   1
51-66% (most of the time)                        0
67-89% (frequently)                              0
90-99% (very frequently)                         0
>99% (always)                                    0
Unknown                                          15
Whatever your previous answer is (if different from “0%”), could you please specify which categories
of injury related deaths it may concern? (19 countries concerned)
All injury related deaths except transport accidents.
For 2005 data: intentional self-harm by unspecified means (X84) and unspecified event, undetermined intent (Y34).
                 These cases represent 3.6% of all R95-R99 codes in the mortality file.
Falls (fracture of hip), accidents, other road traffic accidents.
All categories
Cases after toxicological examination that are impossible to define or other cases from septicaemia (ICD-9 codes 799.9,
                 799.1).
Accidents where effect of trauma is not easily visible (falls, blunt head trauma for example). Domestic violence could
                 fall under here as in so many similar categories. This is the category of diagnoses where instances
                 would be assigned where a doctor issues a certificate without having a specific cause of death but the
                 police would not see reason to ask for a forensic examination (as the rules are here in Iceland).
Drug related deaths or other external deaths for which legal doctor has indicated on the form only "under investigation".
Assaults, suicides
Intentional self-harm by hanging, strangulation and suffocation (X70), assault by hanging, strangulation and suffocation
                 (X91), hanging, strangulation and suffocation, undetermined intent (Y20) coded in ill-defined and
                 unknown causes of mortality (R95-R99).
Almost all codes of external causes of mortality (i.e. transport accidents, falls, drownings, suicides, assaults).
E.g. if body is decomposed.
ANAMORT PROJECT January 2008                                                                         Page 30 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Suicides, homicides and accidents (about 5-8% in 2001/02-data).
E12/ In your country’s statistics, do you think that following underlying causes of death could hide injury
related deaths? (Whatever the reason is: lack of information given by the certifier, application of
codification rules, etc.) [continued]
For each group of underlying cause of death below, indicate roughly the proportion of associated injury related
deaths and specify which types of injury related deaths could mostly be “hidden” by these misclassifications.
ESSL 65: Events of undetermined intent
Include ICD-10 codes Y10-Y34, ICD-9 codes E980-E988, ICD-8 codes E980-E988
0% (never)                                       3
<1% (very rarely)                                5
1-9% (rarely)                                    1
10-33% (sometimes)                               3
34-50% (often)                                   1
51-66% (most of the time)                        1
67-89% (frequently)                              1
90-99% (very frequently)                         1
>99% (always)                                    4
Unknown                                          17
No response                                      1
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice?
Fall due to Epilepsy (seizure)
Coded Epilepsy                                    24
Coded Fall                                        4
It depends                                        7
No response                                       3
Coded Epilepsy
Epilepsy is the main disease.
ICD-10 coding rules, described in the ICD-10 Part 2: Instruction manual, Chapter 4.1.11
Application of codification rules.
We try to select the underlying cause of death according to strict application of ICD-10 rules. Therefore, for a certificate
                 like the above, the General Principle would apply and there is no need to apply any of the modification
                 rules. We also cross check our manual codes with the MMDS software and also use the ACME decision
                 tables to guide our application of the rules. We also have in mind the notes for use in underlying cause
                 mortality coding. They specify that when any accident is reported as resulting from Epilepsy, we should
                 code Epilepsy.
Our coders give a preference to external causes.
The rules as we interpret them.
ICD-10 rules
ICD-10 Volume 2, as exception of highly improbable causal relationships (p. 68).
ICD-10 Vol 2 guideline.
A fall due to Epilepsy is often a consequence of an epileptic status.
We follow the WHO rules and accept the sequence.
Based on what is the originating cause of the fall (the seizure in this instance).
ICD-10 rules and updates.
I assumed that accidental fall was resulted by epilepsy.
Epilepsy is the cause of the fall.
ICD-10 Vol 2, second edition, 4.1.11 (notes for use in underlying cause mortality coding), p 66: Accidents resulting
                 from G40-G41 (Epilepsy), code G40-G41 (p 62 in ICD-10, Vol 2, first edition); or CDC Instruction
                 Manual Part 2a, January 2005 (p 145, G40-G41: Includes accidents resulting from epilepsy; or p
                 163.4.d: some exceptions).
If stated on death certificate.
If serious injury, then according to WHO’s manual, it must be the underlying cause (except for epilepsy). Therefore, it
                 hardly occurs that injury can be found with other underlying causes.
ANAMORT PROJECT January 2008                                                                         Page 31 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
This is the coder's choice.
The rules of ICD-10.
Usually, we considered as cause of death the medical condition (epilepsy, fracture of the basis of the skull, etc.). At
                present, we send instructions concerning the type of accident to be recorded as main cause of death, the
                medical cause being sequenced as secondary diagnosis. A period of time is needed for the physicians to
                get used with this rule.
According to WHO’s international rules.
Following recent WHO guidance (update reference committee).
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Fall due to Epilepsy (seizure) [continued]

It is our routine in order not to lose the non-natural deaths. Epilepsy is mentioned in the part II of the Death Certificate.
Epilepsy as a somatic cause and fall as injury (external cause). If the injury on the body is mentioned, let us say
                  fractured femur, then the fractured femur will be a somatic cause of death and epilepsy will be missed.
                  Violent deaths have priority over "somatic" causes. We send to EUROSTAT codes of "Injury,
                  poisoning and certain other consequences of external causes" codes and not "somatic" codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
On certifiers’ assessment.
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                  of 2006.
How it is written by the certifier.
If fracture, then underlying cause is fracture, else epilepsy.
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Suffocation due to Alzheimer
Coded Alzheimer                                   13
Coded Suffocation                                 9
It depends                                        13
No response                                       3
Coded Alzheimer
Alzheimer is the main disease.
The rules as we interpret them.
Updated ICD-10
Update of linkage rule of ICD-10.
ICD-10 Vol 2 guideline (general principle).
Suffocation due to Alzheimer is often a consequence of Alzheimer.
ICD-10 rules and updates.
Alzheimer disease can be a cause of suffocation.
If stated on death certificate.
The rules of ICD-10.
Suffocation is a symptom that does not have to appear in a death diagnosis, being difficult to be established even if it is
                 real. Most of the deaths occur when the patient is alone without a witness to inform us.
If suffocation due to inhalation. According to WHO’s international rules.
Coded Suffocation
With no additional information on the death certificate and unsuccessful query.
Our coders give a preference to external causes.
It is our routine in order not to lose the non-natural deaths. Alzheimer is mentioned in the part II of the Death
                 Certificate.
If serious injury, then according to WHO’s manual, it must be the underlying cause (except for epilepsy). Therefore, it
                 hardly occurs that injury can be found with other underlying causes.
ANAMORT PROJECT January 2008                                                                         Page 32 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
This is the coder's choice.
It is multiple coding. We do it only for violent deaths where two codes in the data base can be put in. For any manner of
                  suffocation, you can use codes from W65 to W80 and at the same time, if you code also G309, you
                  know that the person suffocated, suffered from Alzheimer disease also. That way more information can
                  be preserved for preventive strategy also for persons suffering from diseases where suffocation is
                  possible. Violent deaths have priority over "somatic" causes. We send to EUROSTAT codes of "Injury,
                  poisoning and certain other consequences of external causes" codes and not "somatic" codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
Following standard ICD-10 rules that External cause takes priority.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Suffocation due to Alzheimer [continued]
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
Different interpretations of 2003 update in ICD-10 volume 2, 4.2.2.: Interpretation of "highly improbable":
                 NOT IMPROBABLE:
                  - Asphyxia due to aspiration of mucus, blood (W80) or vomitus (W78) as a result of disease conditions.
                  - Aspiration of food (liquid or solid) of any kind (W79) reported as due to a disease which affects the
                 ability to swallow.
                 The discussion is whether Alzheimer affects the ability to swallow. Stroke, MS, head or spinal trauma
                 or tumour and neuromuscular diseases can affect the ability to swallow. For Alzheimer, this is not a
                 typical symptom. Suffocation is rare. Pneumonia due to aspiration of food (J69) is more common. The
                 ability to swallow might be affected in a very advanced stadium of Alzheimer only. We therefore follow
                 the opinion of the certifying physician about the sequence of the causes of death. So it depends: if it is
                 mentioned that there are important problems to swallow in an advanced Alzheimer, we will code
                 Alzheimer as underlying cause, otherwise we will code suffocation.
Up to 2005 we coded "Suffocation". Now with the new codification rules for the "highly improbable sequences (i)" we
                 have to decide if asphyxia is due to an aspiration as a result of disease conditions or not.
If suffocation is written on the certificate without specifying that it was a consequence of an external cause, it is coded
                 to R09.0 (asphyxia). In such a case, the General Principle applies and the UCOD is Alzheimer (G03.9).
                 ACME codes like this. However, if suffocation is somehow specified as an external cause, the code it
                 gets is W84 (unspecified threat to breathing). In this case, we would code UCOD: W84 according to the
                 rules and decision tables. In cases like this, clarifications from the police and/or forensic physicians are
                 valuable and we systematically try to get them.
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                 of 2006.
How it is written by the certifier.
Before 2005, we always coded the case to an external cause if any injury was reported. From 2005, if the certifier states
                 that the manner of death was "natural", we accept the sequence and chose Alzheimer. If the certifier
                 states that the manner of death was an external cause, we do not accept the sequence and chose
                 Suffocation.
Alzheimer does not often impair the mobility sufficiently to cause suffocation, unless with for example dysphagia.
Intern laws of automatic coding system STYX: if Alzheimer is described in causes of death as "severe", STYX chooses
                 Alzheimer; if not severity element, STYX chooses suffocation.
On point of view of Forensic med expert.
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Suffocation due to Senility
Coded Senility                                    7
Coded Suffocation                                 17
It depends                                        12
No response                                       2
Coded Senility
ANAMORT PROJECT January 2008                                                                         Page 33 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Senility is the main disease.
The rules as we interpret them.
Updated ICD-10
Suffocation due to Senility is often a consequence of Senility.
ICD-10 rules and updates.
Suffocation is a symptom that does not have to appear in a death diagnosis, being difficult to be established even if it is
                  real. Most of the deaths occur when the patient is alone without a witness to inform us.
It is coded as Senility without mention of psychosis.
Coded Suffocation
With no additional information on the death certificate and unsuccessful query.
Senility is not a disease. It is a code (R54) that is not to be accepted as underlying cause of death if another possibility
                  exists. See coding rules: 4.1.10 of Volume 2 of ICD-10. His age tells already that the person is old.
                  Senility does not cause disability to swallow. The accident prevails.
Our coders give a preference to external causes.
Rule A, volume 2 of ICD-10.
ICD-10 Vol 2 guideline (rule A - senility ill-defined).
We do not accept Senility as a condition giving rise to Suffocation.
Rule A, volume 2 of ICD-10.
It is our routine in order not to lose the non-natural deaths. Senility is mentioned in the part II of the Death Certificate.
More precise than senility.
If serious injury, then according to WHO’s manual, it must be the underlying cause (except for epilepsy). Therefore, it
                  hardly occurs that injury can be found with other underlying causes.
This is the coder's choice.
The rules of ICD-10.
According to WHO’s international rules.
It is multiple coding. We do it only for violent deaths where two codes in the data base can be put in. For any manner of
                  suffocation, you can use codes from W65 to W80 and at the same time, if you code also R54, you know
                  that the person suffocated, suffered from Senility disease also. That way more information can be
                  preserved for preventive strategy also for persons suffering from diseases where suffocation is possible.
                  Violent deaths have priority over "somatic" causes. We send to EUROSTAT codes of "Injury,
                  poisoning and certain other consequences of external causes" codes and not "somatic" codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
Following standard ICD-10 rules that External cause takes priority.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Suffocation due to Senility [continued]
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
Up to 2005 we coded "Suffocation". Now with the new codification rules for the "highly improbable sequences (i)" we
                 have to decide if asphyxia is due to an aspiration as a result of disease conditions or not.
If suffocation is written on the certificate without specifying that it was a consequence of an external cause, it is coded
                 to R09.0 (asphyxia). In such a case, the General Principle applies and the UCOD is Senility. ACME
                 codes like this. However, if suffocation is somehow specified as an external cause, the code it gets is
                 W84 (unspecified threat to breathing). In this case, we would code UCOD: W84 according to the rules
                 and decision tables. In cases like this, clarifications from the police and/or forensic physicians are
                 valuable and we systematically try to get them.
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                 of 2006.
How it is written by the certifier.
Query senility.
Senility does not often impair the mobility sufficiently to cause suffocation, unless with for example dysphagia.
Intern laws of automatic coding system STYX: if senility is described in causes of death as "severe", STYX chooses
                 senility; if not severity element, STYX chooses suffocation.
On point of view of Forensic med expert.
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.

ANAMORT PROJECT January 2008                                                                         Page 34 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Suffocation due to Mental disorder
Coded Mental disorder                               13
Coded Suffocation                                   12
It depends                                          11
No response                                         2
Coded Mental disorder
Mental disorder is the main disease.
Updated ICD-10
ICD-10 Vol 2 guideline (general principle).
Suffocation due to Mental disorder is a consequence of these mental disorders.
It can cause the individual to put things in his mouth without being aware (as an infant would) and also can affect table
                  manners, not chewing food sufficiently, etc.
ICD-10 rules and updates.
Intern laws of automatic coding system STYX.
If stated on death certificate.
The rules of ICD-10.
Suffocation is a symptom that does not have to appear in a death diagnosis, being difficult to be established even if it is
                  real. Most of the deaths occur when the patient is alone without a witness to inform us.
If suffocation due to inhalation. According to WHO’s international rules.
Coded Suffocation
With no additional information on the death certificate and unsuccessful query.
Mental disorder is a vague term. See coding rules: 4.1.10 of Volume 2 of ICD-10. Mental disorder does not cause
                  disability to swallow. The accident prevails.
Our coders give a preference to external causes.
The rules as we interpret them.
I prefer external cause to disease condition.
It is our routine in order not to lose the non-natural deaths. Mental disorder is mentioned in the part II of the Death
                  Certificate.
If serious injury, then according to WHO’s manual, it must be the underlying cause (except for epilepsy). Therefore, it
                  hardly occurs that injury can be found with other underlying causes.
This is the coder's choice.
It is multiple coding. We do it only for violent deaths where two codes in the data base can be put in. For any manner of
                  suffocation, you can use codes from W65 to W80 and at the same time, if you code also F00-F99, you
                  know that the person suffocated, suffered from Mental disorder disease also. That way more
                  information can be preserved for preventive strategy also for persons suffering from diseases where
                  suffocation is possible. Violent deaths have priority over "somatic" causes. We send to EUROSTAT
                  codes of "Injury, poisoning and certain other consequences of external causes" codes and not "somatic"
                  codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
Following standard ICD-10 rules that External cause takes priority.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Suffocation due to Mental disorder [continued]
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
Up to 2005 we coded "Suffocation". Now with the new codification rules for the "highly improbable sequences (i)" we
                 have to decide if asphyxia is due to an aspiration as a result of disease conditions or not.
If suffocation is written on the certificate without specifying that it was a consequence of an external cause, it is coded
                 to R09.0 (asphyxia). In such a case, the General Principle applies and the UCOD is Mental disorder.
                 ACME codes like this. However, if suffocation is somehow specified as an external cause, the code it
                 gets is W84 (unspecified threat to breathing). In this case, we would code UCOD: W84 according to the
                 rules and decision tables. In cases like this, clarifications from the police and/or forensic physicians are
                 valuable and we systematically try to get them.
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                 of 2006.
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Update of linkage rule of ICD-10.
How it is written by the certifier.
Before 2005 we always coded the case to an external cause, if any injury was reported. From 2005, if the certifier states
                that the manner of death was "natural", we accept the sequence and chose the Mental disorder. If the
                certifier states that the manner of death was an external cause, we do not accept the sequence and chose
                Suffocation.
On point of view of Forensic med expert.
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Traffic accident due to Heart attack
Coded Heart attack                                 11
Coded Traffic accident                             16
It depends                                         8
No response                                        3
Coded Heart attack
Heart attack would be the underlying cause of death.
Heart attack is the main disease.
In this case the heart attack is clearly the underlying cause. To prevent this event, we would need to prevent the heart
                 attack.
The rules as we interpret them.
A traffic accident is a consequence of Heart attack.
Based on what is the originating cause of the accident, since a heart attack can render a driver unconscious in a short
                 time period, not giving him time to stop the car and securing himself with regards to other traffic.
CDC Instruction Manual Part 2a, January 2005 [p 162-164] (V01-Y89: When the morbid condition is classified to
                 Chapters I-XVIII, the morbid condition itself should be coded as the underlying cause; or Accident due
                 to disease condition (cerebral haemorrhage, heart attack) is indicated by certifier to be underlying cause
                 of the accident; or else: the assignment is made to the accidental cause unless there is evidence that the
                 death occurred prior to the accident). Also, if heart attack recorded on lowest line (due to).
This is the coder's choice.
The death is due to a cardiopathy if the driver in the traffic accident is recorded as suffering of cardiopathy especially in
                 case of an old myocardial infarction or rhythm troubles. We shall establish with specialists to consider
                 the traffic accident as main diagnosis too, the medical cause being secondary diagnosis.
Coded Traffic accident
ICD-10 rules
List of highly improbable causal relationship, ICD-10 volume 2.
ICD-10 Vol 2 guideline (4.2.2.m).
Because if a person were somewhere else perhaps he would be alive.
ICD-10 rules and updates.
I prefer external cause to disease condition.
Intern laws of automatic coding system STYX.
It is our routine in order not to lose the non-natural deaths. Heart attack is mentioned in the part II of the Death
                 Certificate.
If serious injury, then according to WHO’s manual, it must be the underlying cause (except for epilepsy). Therefore, it
                 hardly occurs that injury can be found with other underlying causes.
The rules of ICD-10.
According to WHO’s international rules.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Traffic accident due to Heart attack [continued]
Coded Traffic accident [continued]
These are very rare cases. It is hard to determine that person had heart attack when driving car, and as a consequence of
                heart attack traffic accident happened. But sometimes it is truly a reason, and these cases go at this kind

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collected from our network of national experts in mortality and injury"
                  of multiple coding. We send to EUROSTAT codes of "Injury, poisoning and certain other consequences
                  of external causes" codes and not "somatic" codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
Following standard ICD-10 rules that External cause takes priority.
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
In such cases we try to clarify the exact circumstances of death by contacting the police. They get a detailed confidential
                  report from the forensic physician specifying whether the cause of death was the accident or the heart
                  attack. (We do not get a complete death certificate from the forensic physician because of a pending
                  legal framework for our Unit). When we get a clarification we code accordingly. If there is no
                  clarification we code to traffic accident because the external cause appears on the certificate.
Our coders give a preference to external causes but in some specific cases, their decisions may differ (e.g. traffic
                  accident due to heart attack - some may select as UC heart attack).
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                  of 2006.
In our death certificate a check box is used to define the manner of death. If the certifier checks the answer accident and
                  mix the natural and external causes but puts the external cause into Part I, we always consider the case
                  as an accident caused by an external cause.
Depends on review of autopsy result
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Drowning due to Heart attack
Coded Heart attack                                   11
Coded Drowning                                       17
It depends                                           7
No response                                          3
Coded Heart attack
Heart attack is the main disease.
In this case the heart attack is clearly the underlying cause. To prevent this event, we would need to prevent the heart
                  attack.
The rules as we interpret them.
Drowning is a consequence of Heart attack.
Based on what is the originating cause of the accident, since a heart attack can render a swimmer unconscious in a short
                  time period, not giving him time to get to the shore.
CDC Instruction Manual Part 2a, January 2005 [p 162-164] (V01-Y89: When the morbid condition is classified to
                  Chapters I-XVIII, the morbid condition itself should be coded as the underlying cause; or Accident due
                  to disease condition (cerebral haemorrhage, heart attack) is indicated by certifier to be underlying cause
                  of the accident; or else: the assignment is made to the accidental cause unless there is evidence that the
                  death occurred prior to the accident); Also, depends on line what and where "due to" interpretation
                  reported by the certifier (i.e. forensic med expert).
If the patient did not have heart attack, he probably would not have drowned.
The death is due to a cardiopathy if the driver in the traffic accident is recorded as suffering of cardiopathy especially in
                  case of an old myocardial infarction or rhythm troubles. We shall establish with specialists to consider
                  the traffic accident as main diagnosis too, the medical cause being secondary diagnosis.
Coded Drowning
Drowning is an external cause (W74) and according to the rules and decision tables, it cannot be caused by conditions
                  other than epilepsy. Therefore we code to Drowning.
ICD-10 rules
It is a highly improbable causal relationship, ICD-10 volume 2.
ICD-10 Vol 2 guideline (4.2.2.m).
Because if a person were somewhere else perhaps he would be alive.
ICD-10 rules and updates.
I prefer external cause to disease condition.
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Intern laws of automatic coding system STYX.
It is our routine in order not to lose the non-natural deaths. Heart attack is mentioned in the part II of the Death
                 Certificate.
If serious injury, then according to WHO’s manual, it must be the underlying cause (except for epilepsy). Therefore, it
                 hardly occurs that injury can be found with other underlying causes.
This is the coder's choice.
The rules of ICD-10.
According to WHO’s international rules.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Drowning due to Heart attack [continued]
Coded Drowning [continued]
These are very rare cases. It is hard to determine that person had heart attack when swimming, and as a consequence of
                  heart attack drowning happened. But sometimes it is truly a reason, and these cases go at this kind of
                  multiple coding. We send to EUROSTAT codes of "Injury, poisoning and certain other consequences of
                  external causes" codes and not "somatic" codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
Following standard ICD-10 rules that External cause takes priority.
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
Depends on what we know.
Our coders give a preference to external causes but in some specific cases, their decisions may differ (e.g. drowning due
                  to heart attack - some may select as UC heart attack).
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                  of 2006.
In our death certificate a check box is used to define the manner of death. If the certifier checks the answer accident and
                  mix the natural and external causes but puts the external cause into Part I, we always consider the case
                  as an accident caused by an external cause.
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Pulmonary embolism due to Femoral fracture following Fall
Coded Fall                                         22
Coded Femoral fracture                             4
Coded Pulmonary embolism                           2
It depends                                         7
No response                                        3
Coded Fall
Because fall is mentioned, we code fall. If fall would not be mentioned, we would code femoral fracture.
Application of ICD-10 rules.
Pulmonary embolism is a non-specific condition and can be caused by a number of other more specific conditions. The
                 rules and decision tables lead to the external cause as the underlying cause of death.
We process both codes, external and T-S code (nature of injury). For statistic purposes, we use code for external cause.
The rules as we interpret them.
General rule, pulmonary embolism is the secondary disease, it is tried to find the reason of it.
ICD-10 Vol 2 guideline (general principle).
We follow the WHO rules and accept the sequence.
After a fracture, the individual is at increased risk of getting venous thromboses and pulmonary embolism as a result,
                 therefore the fall can cause the embolism.
Pulmonary embolism was a consequence of fracture of femur which was caused by fall.
Unspecified fall: after applying selection and modification rules (selection Rule 3, direct sequel). Since fall is the
                 primary condition, consequences are the fracture and its complications.
It is our routine in order not to lose the non-natural deaths. Pulmonary embolism due to Femoral fracture is mentioned
                 in the part II of the Death Certificate.
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collected from our network of national experts in mortality and injury"
According to ICD-10 rules.
This is the coder's choice.
The rules of ICD-10.
According to WHO’s international rules.
It is multiple coding. We do it only for violent deaths where two codes in the data base can be put in. Violent deaths
                  have priority over "somatic" causes. We send to EUROSTAT codes of "Injury, poisoning and certain
                  other consequences of external causes" codes and not "somatic" codes.
If injury related causes of death are stated in the report, they have priority when selecting the underlying cause of death.
Following standard ICD-10 rules that External cause takes priority.
E13/ When selecting the underlying cause of death, how would you deal with following sequences and
why would you make this choice? [continued]
Pulmonary embolism due to Femoral fracture following Fall [continued]
Coded Femoral fracture
Femoral fracture is the main disease.
ICD-10 rules.
Pulmonary embolism is a consequence of a Femoral fracture. We also select external cause of death.
Coded Pulmonary embolism
We do not use chapter XIX (S00 to T98) ICD-10 codes for underlying causes of death. These codes are only used for
                 double coding of external causes of death (chapter XX V01 to Y98).
It depends
Depends on initial cause given by the certifier and the notes of the certifier.
On certifiers’ assessment.
We apply the ICD-10 rules, guidelines for mortality (Section 4.22 'Interpretation of highly improbable') and the updates
                 of 2006.
We code and disseminate (for violent causes) both the manner of death (here, fall - underlying external cause) and the
                 type of lesion (here, femoral fracture).
If all occurs in a short period: code Femoral fracture. If fall and fracture more than 28 days before then Y86 (Sequelae
                 of other accidents) and T93.1 (Sequelae of fracture of femur).
Coded according to the causal relationship tables, coroner's verdict and international rules.
Depends on which part causes of death are in the certificate.
E14/ Can you mention any other sequence involving injury where the selection of underlying cause of
death can be difficult to define?
Cerebral haemorrhage
Cancer with metastasis in bone, bone fracture in neoplasm (M90.7) with or without fall, pathological fracture in
                 osteoporosis with or without fall (M80).
Injury related deaths or poisoning of injection drug users.
Accident due to drugs.
Fracture due to cerebrovascular disease, osteoporosis.
Mostly problems of intent (natural versus suicide, homicide).
If two or more external causes as sequence.
Alcohol consumption with accidents.
Mental retardation, suffocation.
If a tetanus infection was reported due to an accident, we code the infection. If inhalation of blood was reported due to
                 malignant neoplasm, the malignant neoplasm is coded.
Alcohol/drug related accidents. Dependence versus non-dependence.
Accidents in medical cares.
Coronary disease on day of surgery. Coronary disease and medical devices.
Fall from height after alcohol intoxication.
1) minor head injury that lead to cerebral haemorrhage after some days 2) injury that lead to surgery for injury that lead
                 to complications of surgery 3) anti-coagulants + CVA + fall if all at the same time or at unspecified
                 time.
E15/ Do you use an automated coding process to determine ICD codes and underlying cause of death?
Yes                                              12
No                                               26
Unknown                                          0
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collected from our network of national experts in mortality and injury"
E16/ If Yes, specify the software used and its version (NB: the current version) (12 countries concerned)
MMDS V2 (2005). We use MMDS software for automatic coding. We have started using MMDS (Supermicar, Micar,
               Acme/Transax) since 2004. We use the original software without any translation in the software itself.
               Whenever we have a certificate in Greek, the translation is made by trained coders.
ACME 2000.0.1.54 (2002)
Home made. They do not use decision tables for the selection of the underlying cause. They work based upon data bases
               introduced manually with the causes of death registered. When a sequence (of causes) is entered, the
               system checks if it contains the same sequence and in this case it assigns the same code for the
               underlying cause. At national level we plan to use IRIS as soon as it is available (maybe 2007).
ACME 2005.02 (2005). ACME program is used as the inference of the underlying cause of death. First, we make the
               manual coding and after that, feed all causes of death to ACME program and use it as an error list for
               the underlying cause.
STYX V3 (2001)
National software using decision tables of MMDS 2003 (2005). The national software is a JAVA application in
               ORACLE database using the algorithm of ACME.
MICAR-ACME for PC ICD-10, 2005 version (2003)
STYX V3.10 S/V (2004). Version from March 2003 used for coding causes of death during the year 2004. This
               automatic coding system has been elaborated by the CépiDc-INSERM. It is useful for coding the cause
               of death written in French but this is not the only language used by patricians in Luxembourg, also
               German, sometimes Luxemburgish, even Latin.
E16/ If Yes, specify the software used and its version (NB: the current version) [continued]
ACME (Each year has been coded using the latest available version of ACME)
NCHS 2001.2 (2001)
NCHS, ICD-10 (2000)
MMDS 2003 2000.0.1.54 (2003)
E17/ If No, do you plan to use it? (26 countries concerned)
Yes, in a specific year                          11       2007 (4) 2008 (4) 2010 (2) 2011 (1)
Yes but year unknown                             7
No, not planned                                  4
Unknown                                          0
No response                                      4
Chapter F/ Query practices in 2005-2006
F1/ In cases where an investigation (or inquiry) is done, who fills in the death certificate?
The first physician who initially certified the death
Yes                                              25
No                                               11
Unknown                                          1
No response                                      1
A second physician
Yes                                              10
No                                               22
Unknown                                          3
No response                                      3
A forensic physician
Yes                                              30
No                                               7
Unknown                                          1
A legal professional
Yes                                              11
No                                               22
Unknown                                          2
No response                                      3
F1/ In cases where an investigation (or inquiry) is done, who fills in the death certificate? [continued]
Police
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collected from our network of national experts in mortality and injury"
Yes                                              0
No                                               35
Unknown                                          1
No response                                      2
Another person
Yes                                              3
No                                               28
Unknown                                          1
No response                                      6
F2/ After these investigations (or inquiry), are the results (new or more precise causes of death)
included in the final mortality statistics?
Always                                           19
Most of the time                                 15
Sometimes                                        4
Never                                            0
Unknown                                          0
F3/ Are queries to certifiers (questions asked by the statistics/coding office) possible when the
statistics/coding office needs to get more precise information on an individual cause of death (whatever
the cause is)?
Yes                                              12
Yes but difficult                                24
No                                               2
Unknown                                          0
F4/ If it is difficult or not possible to query the certifiers, what could contribute to this? (26 countries
concerned)
Confidentiality constraint
Yes                                              11
No                                               11
Unknown                                          2
No response                                      2
Difficulty in identifying the certifier
Yes                                              14
No                                               10
Unknown                                          1
No response                                      1
Difficulty for the certifier to identify the case
Yes                                              12
No                                               9
Unknown                                          3
No response                                      2
Lack of resources
Yes                                              15
No                                               7
Unknown                                          3
No response                                      1
F4/ If it is difficult or not possible to query the certifiers, what could contribute to this? [continued]
Other reason
Yes    11      Time consuming and no willingness to give info. Others from doctors give information, doctors are
  rarely reachable. NSI processes statistical notifications of death, which are completed by registry offices according
  to the primary death certificate. Thus, NSI can only ask registry officers for clarification but in case if problems
  occur originally on the primary DC, generally they do not ask certifiers for clarification. Old person who never (last
  10 years) been treated by any doctor. Difficulty in identifying the certifier only occurs in Budapest where a large
  migration of physicians among work places was detected. Other difficulty is the negative attitude against statistical
  data supply. Most of the death certificates, in nowadays, badly filled in because of lack of importance given by such
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collected from our network of national experts in mortality and injury"
   a work (death certification) for public health issue. Death certification can also be seen only as an administrative
   obligation. Sometimes the certifier is known but not the treating physician. The major problem in querying is non
   response of certifier. Certifiers not keen to answer our queries
No                                                 2
Unknown                                            3
No response                                        10
F5/ If the cause of death is undetermined, is the certifier questioned by the statistics/coding office?
Never                                            6
Sometimes                                        11
Often                                            8
Systematically                                   11
Unknown                                          2
F6/ For the most recent year completed, among deaths from all causes, what is the proportion of death
certificates that were queried (questions asked by statistics/coding office to the certifier)?
<1%                                              9
1-9%                                             20
10-33%                                           5
34-50%                                           1
51-66%                                           0
67-89%                                           0
90-99%                                           0
>99%                                             0
Unknown                                          3
Which year
2005                                             10
2004                                             14
2003                                             6
2002                                             1
2001                                             1
Not answered                                     6
F7/ Is there a significant evolution in the proportion of death certificates that are queried (whatever the
causes of death are)?
Increasing                                       6
Decreasing                                       10
Stable (no evolution)                            19
Unknown                                          3
F8/ How could you explain this? (35 countries concerned)
Increasing proportion of queried death certificates
Low quality
It is only recently that we have started proper codification of Causes of Death. Our processes are under development
                 and for the time being there is an increasing tendency of death certificates that are queried. We expect
                 that with proper training of the certifiers, the trend will be reversed.
Because more death certificates need legal autopsy from a legal professional and we want to do better our job.
Change in the person in charge of registry.
More resources for querying.
We changed the age limit from 75 to 80.
Decreasing proportion of queried death certificates
Continuous education of certifiers.
The learning process, the use of the medical consults.
There was an intensive campaign in 2005 to inform certifiers about required practice.
Coders' access to internet.
Certifiers become more precise filling in the medical part of death certificate.
Many certificating physicians, after a query about a death certificate, improve the quality of information declared on the
                death certificate.
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collected from our network of national experts in mortality and injury"
Quality of filling in certificates is improving.
Due to educational efforts of the staff of the Institute of Epidemiology and Biostatistics in Medical Faculty of Skopje.
Better knowledge of ICD-10 rules both from certifier and coder.
Several problems to solve, the Civil Register has started to be private and now they ask us for money to have a print
                 copy of the certificate of death. This certificate has, since 2002, a self-copy that the Civil Register keeps
                 with the original.
Stable proportion of queried death certificates
Started to select information on querying 2004.
Lack of resources
About 5 years ago, we reduced the number of queries associated with very specific cancer sites (this information would
                 generally be available to researchers in Scotland from the cancer registry)
F9/ Are there any standardized instructions/protocols for sending queries (whatever the causes of death
are)?
Yes                                               11
No                                                26
Unknown                                           1
F10/ If Yes, specify (11 countries concerned)
Letter with querying reason, death certificate which is queried (copy).
Standardized questions to some not very clearly defined causes of death on the certificate, like questions for causes of
                  injuries, underlying disease of embolism, localisation of neoplasm, etc.
Questionnaire
More queries for low ages.
Form attached.
For those where final results from autopsy or lab results were missing when the certificate was filled out.
Brief list of reasons for querying.
Guidelines related to specific causes.
Sweden has pre-made queries; we have recently risen the age for queries from 75 to 80.
There is a standardised formulary:
                  - Where the scheme of underlying cause of death is drown.
                  - The examples how underlying cause and external cause of death have to be filled in.
                  - What additional information we need for particular case which we are querying.
Many queries are generated automatically by the computer system.
F11/ Are there recommendations to query certain causes of death as a matter of priority, more
systematically than others?
Yes                                               13
No                                                25
Unknown                                           0
F12/ If Yes, specify concerned causes of death (13 countries concerned)
Alcohol, drugs, undetermined, under age of 80.
Standardized questions to some not very clearly defined causes of death on the certificate, like questions for causes of
                injuries, underlying disease of embolism, localisation of neoplasm and for the maternal mortality.
Mainly when only unknown and unspecified COD are mentioned. Otherwise, often occurred, case for querying is when
                injury is mentioned without mechanism of death (if it was accident, suicide etc.).
Creutzfeldt-Jakob related deaths.
Missing external causes, neoplasm primary yes/no, the cause is symptom, signs, etc.
Unknown causes, violent deaths (intent), Aids.
F12/ If Yes, specify concerned causes of death [continued]
External causes, malignant neoplasm, recent surgery. Querying external causes is a matter of priority because the
               circumstances, date and place of injury are often poorly reported. In Hungary, the majority of the
               queries are performed before the data entry. After a Death Certificate was filled out and sent to the
               Regional Statistical Office, a local health officer checks the medical information following rules the
               Statistical Office provided him/her. Since querying precedes the data processing, we are able to estimate
               the proportion of queried certificates even before the closure of the data year.


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"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Not in terms of cause of death but all perinatal death certificates (stillbirths and deaths aged less than 10 days) are
                controlled.
Specific causes and age groups, and region (no query if death outside institution in Oslo, source Statistics Norway
                coding documentation from 1998 data).
External causes and symptoms, signs, abnormal findings, ill-defined causes.
Pneumonias, heart failures, ill-defined circulatory and respiratory conditions, complications of surgery, ill-defined
                tumours.
We do not systematically query certain causes. However, the death is not allowed to be registered if certain causes are
                written on the death certificate on their own. The registrar will refer these deaths to the coroner.
As well as incomplete or poorly completed certificates we specifically query potential drug-related deaths and potential
                HIV/AIDS deaths.
F13/ Do certifiers have an age limit beyond which they stop querying?
Yes                                              12
No                                               26
Unknown                                          0
If Yes, specify the age limit (12 countries concerned)
Often 80 Or 75
If injury related, then age does not play a role. If cancer in a person over 80, no query will be done to get to know what
                  cancer exactly. For the Walloon region: age limit is 80 years-old.
Maternal mortality: women aged 15-50 years, others regardless of the age of the deceased.
After 85 years-old, Senility (K54) is accepted.
It is not well defined; we only say "old age". In general, we mean older than 70.
Less likely to query for over 85.
It differs: some 70+, some 75+. If mors subita and deaths at home: no query if 70+. If mors subita and deaths in
                  institution, no query if 85+.
F14/ What is the median delay in months between death and the attribution of an ICD code?
Immediately                                      1
1 month                                          8
2 months                                         8
3 months                                         5
4 months                                         1
5 months                                         1
6 months                                         7


8 months                                         1
10-12 months                                     1
20 months                                        2
24 months                                        1
30-36 months                                     1
Unknown                                          1
F15/ If the reported underlying cause of death is “ill-defined or otherwise unsatisfactory”, do the coders
try to obtain further information (request)?
Always                                           7
Most of the time                                 17
Sometimes                                        12
Never                                            2
Unknown                                          0
F16/ In the most recent year completed, among external causes of deaths (ESSL 58-65 and ICD-10 S00 -
Y98), what was the proportion of death certificates that were queried?
<1%                                              10
1-9%                                             7
10-33%                                           6
34-50%                                           4
51-66%                                           0
ANAMORT PROJECT January 2008                                                                         Page 44 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
67-89%                                           1
90-99%                                           2
>99%                                             0
Unknown                                          8
Which year
2005                                             11
2004                                             9
2003                                             4
2002                                             1
Unknown                                          1
Not answered                                     12
F17/ Concerning deaths due to external causes, is there any standardized instruction to query
certifiers?
Yes                                              9



No                                               28


Unknown                                          1
Chapter G/ Statistic production, coverage and quality indicators
G1/ What is the definition of a resident in your country (multiple answers possible)?
Living more than 3 months in the country
Yes                                              3
No                                               32
Unknown                                          1
No response                                      2
Living more than 6 months in your country
Yes                                              6
No                                               28
Unknown                                          2
No response                                      2
Having the nationality of the country
Yes                                              6
No                                               32
Unknown                                          0
Having a resident card or permit
Yes                                              15
No                                               19
Unknown                                          2
No response                                      2
G1/ What is the definition of a resident in your country (multiple answers possible)? [continued]
Having a working permit
Yes                                              6
No                                               30
Unknown                                          2
Paying national income taxes
Yes                                              2
No                                               33
Unknown                                          3
Registered as resident in the population registry
Yes                                              23
No                                               14
Unknown                                          0
No response                                      1
ANAMORT PROJECT January 2008                                                                         Page 45 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Born in the country
Yes                                              6
No                                               31
Unknown                                          1
G1/ What is the definition of a resident in your country (multiple answers possible)? [continued]
Other definitions
Usual residence (place of usual residence is the geographic place where enumerated person usually resides).
On the death certificate, usual place of staying filled in by the medical doctor and checked by the officer of the
                 community where the person died.
The statistical definition of the Resident population includes people who live permanently in the country and have not
                 left it officially as of the 31.12 of the respective year for the period of more than one year. The Law of
                 the Foreigners in our county defines legal rules on resident’s status.
Living or intend to live at least 1 year.
Or specified on medical Death Certificate by doctor or Civil Registration Office.
The person living or going to live one year in the country is registered as permanent resident in the population registry.
Living 6 months with the intention to stay more. The unknown answers are not necessary presuppositions for someone
                 to be resident.
Living more than 12 months.
Informant registering death says deceased lived at an address in Ireland.
Almost all people having a working permit and/or a permit to stay in Italy are registered as resident in the population
                 register, because a working permit is a clause to obtain a permit of staying.
People who have place of usual residence abroad but are present in the country more than a year and have a residence
                 permit.
Persons registered on permanent stay in the country.
Has permanent or temporary residence.
Permanent residence only.
Informant registering the death says the deceased lived at an address in the country.
Address of usual residence as supplied by person registering the death.
Usual address
G2/ If one of the residents of your country dies abroad…
Do you collect information?
Always                                           14
Most of the time                                 6
Sometimes                                        8
Never                                            10
Unknown                                          0
Do you include this information in your published statistics? (28 countries concerned)
Yes but separately                               3
Yes and included in the whole statistics         19
No                                               6
Unknown                                          0
G2/ If one of the residents of your country dies abroad… [continued]
Do you transmit this case to Eurostat? (28 countries concerned)
Yes but separately                               0
Yes and included in the whole data set           17
No                                               11
Unknown                                          0
Do you transmit this case to WHO? (28 countries concerned)
Yes but separately                               0
Yes and included in the whole data set           17
No                                               11
Unknown                                          0
G3/ Out of all deaths, what is the estimated proportion of national residents dying abroad?
Lower than 0.1%                                  8
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"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
From 0.2 to 0.4%                                 4
From 0.5 to 0.9%                                 11
From 1 to 4%                                     6
5% or more of all deaths                         0
Unknown                                          9
G4/ What is the source of this estimate? (29 countries concerned)
Cross-sectional study                            5
Continuous death certificate analysis            17
Feeling                                          6
Unknown                                          0
No response                                      1
G5/ Out of deaths due to external causes, what is the estimated proportion of your national residents
dying “abroad”?
Lower than 1%                                    12
From 1 to 4%                                     6
From 5 to 9%                                     1
From 10 to 24%                                   0
25% or more of deaths due                        0
to external causes
Unknown                                          19
G6/ What is the source of this estimate? (19 countries concerned)
Cross-sectional study                            0
Continuous death certificate analysis            10
Feeling/guess                                    8
Unknown                                          1
G7/ If a person considered as a non-resident dies in your country…
Do you collect the information in your database?
Always                                           24
Most of the time                                 1
Sometimes                                        3
Never                                            10
Unknown                                          0
Do you include this information in your published statistics? (28 countries concerned)
Always                                           15
Most of the time                                 0
Sometimes                                        1
Never                                            12
Unknown                                          0
G7/ If a person considered as a non-resident dies in your country… [continued]
Do you transmit these cases to Eurostat?
Yes but separately                               1
Yes and included in the whole statistics         13
No                                               24
Unknown                                          0
Do you transmit these certificates to the country of the non resident?
Always                                           8
Most of the time                                 1
Sometimes                                        3
Never                                            21
Unknown                                          4
No response                                      1
G8/ Out of all deaths, what is the estimated proportion of non-residents dying in your country?
Lower than 0.1%                                  6
From 0.2 to 0.4%                                 9
ANAMORT PROJECT January 2008                                                                         Page 47 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
From 0.5 to 0.9%                                 11
From 1 to 4%                                     4
5% or more of all deaths                         1
Unknown                                          7
G9/ What is the source of this estimate? (31 countries concerned)
Cross-sectional study                            2
Continuous death certificate analysis            23
Feeling/guess                                    6
Unknown                                          0
G10/ Out of deaths due to external causes, what is the estimated proportion of non-residents dying in
your country?
Lower than 1%                                    16

From 1 to 4%                                     8
From 5 to 9%                                     2
From 10 to 24%                                   3
25% or more of deaths due                        0
to external causes
Unknown                                          9
G11/ What is the source of this estimate? (29 countries concerned)
Cross-sectional study                            2
Continuous death certificate analysis            21
Feeling/guess                                    6
Unknown                                          0
G12/ Independently of the mortality statistics produced from medical death certification data, which
sources of information are available to give an estimate of the annual number of deaths?
Demographic mortality data
Yes                                              21
No                                               16
Unknown                                          1
Census data
Yes                                              3
No                                               33
Unknown                                          2
G12/ Independently of the mortality statistics produced from medical death certification data, which
sources of information are available to give an estimate of the annual number of deaths? [continued]
Central population register
Yes                                              20

No                                               17
Unknown                                          1
Funeral services statistics
Yes                                              3
No                                               33
Unknown                                          2
Cross sectional surveys
Yes                                              1
No                                               34
Unknown                                          3
Social insurance services database
Yes                                              3
No                                               34
Unknown                                          1
Hospital database
ANAMORT PROJECT January 2008                                                                         Page 48 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Yes                                              12
No                                               25
Unknown                                          1
G13/ Other sources
Yes                                               9       Information system “Death certificate” (i.e. collection of
 information from the primary death certificates). All deaths: The Population information system of Population
 Register Centre. Stillbirths: The register of births. The only source of number of deaths is Statistical survey of death
 (cause of death is based on certificate of death). Local registration offices. We do have some independent sources for
 certain specific categories of deaths, e.g. homicides, road traffic accidents, infant mortality. Nationwide cancer and
 heart attack registries. Central Statistical Bureau database of causes of death. Demographic mortality data and medical
 part of death certificate are completed on same form by same person. We check with public registry department who
 receive identity card of the deceased. There are several sources for non-natural deaths (i.e. external causes). Besides
 the cause of death certificate, we use police records for traffic accidents and court records. This helps to overcome
 some lack of information on the CoD certificate.
No                                                18
Unknown                                           5
No response                                       6
G14 When comparing Cause of Deaths (CoD) data to an external source (i.e. demographic mortality
data), what is the approximate proportion of deaths for which the CoD statistics office does not receive
the medical part of the death certificate? (31 countries concerned)
Specify source of comparison and % (# missing medical part of death certificates/#deaths)
0%                                               5
<1%                                              11
1% or more                                       6
No comparison done                               2
Unknown/Not specified                            7
G15/ Among all death certificates, what is the proportion of certificates that arrives with no medical
information?
Lower than 1%                                    23
From 1 to 4%                                     7
From 5 to 9%                                     4
From 10 to 24%                                   0
25% and more                                     0
Unknown                                          4
G16 If a death certificate has no information on the cause of death, is that death still included in the
statistics?
Yes                                              35
No                                               3
Unknown                                          0
In this case, which ICD code would be entered in the database according to your ICD version? (35
countries concerned)
ICD-10 – R99                                     20
ICD-10 – R95-R99                                 6
ICD-9 – 799                                      4
Other                                            2
No response                                      3
G17/ Are studies of the reliability of causes of death statistics done in your country (i.e. comparison of
individual causes of death with other medical records)?
Yes                                              12
No                                               25
Unknown                                          1
G18/ If Yes, what are the main results? (12 countries concerned)
Or specify the references of the reports, publications and/or articles

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"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
G19/ In your opinion, do certain deaths typically lack information on causes of death more than others
(i.e.: deaths investigated at a forensic institute, deaths at nursing homes, HIV related deaths, deaths
occurring in an emergency unit, etc.)?
Yes                                              23
No                                               9
Unknown                                          6
G20/ If Yes, specify causes/circumstances of concerned deaths (23 countries concerned)
Death in higher aged.
Deaths occurring in emergency units, injury related deaths in prisons, injury related deaths of policemen and military
                 people, suicides, overdoses.
Violent deaths
Deaths of women occurring after delivery.
Transport accidents, suicides, use of drugs, HIV.
Deaths of residents died abroad, deaths investigated at emergency unit.
Malignant neoplasm with or without specification of site.
Forensic
Infant deaths, deaths in emergency units, injury related deaths.
Forensic institutes, emergency units.
Drugs and HIV related deaths.
Deaths certified by a doctor on duty, alcohol dependence in general and if a toxicological analysis has to be made.
Nursing homes, geriatric hospitals.
Deaths referred to unknown people and generally deaths for non-natural causes e.g. deaths in the sea after a shipwreck.
The results of the investigation concerning deaths dues to poisoning by drugs, medicaments and biological substances
                 are not communicated to our service.
Lack of information in emergency units, at nursing homes, lack of previous diseases, life anamnesis.
AIDS, alcohol related deaths, suicides.
Deaths in nursing homes, among very old, deceased at home, seen by doctor-on-call and surgeon sometimes only sate
                 procedures not diagnosis.
Deaths outside hospital, deaths at home, death certificates issued by forensic institute often lack information on cause.
Elderly dying at home, deaths in nursing homes, clinics for long-time mental care.
Deaths of Slovene residents who died abroad.
HIV, homicides, accelerated registrations.
Very elderly
G21/ When calculating standardised mortality rates for your country, which variable do you use?
Age and sex                                      27
Age alone                                        6
Sex alone                                        0
Other                                            1
No standardised mortality rates                  3
Unknown                                          1
G22/ If other, specify (1 country concerned)
AT               Age, sex and NUT2.
G23/ Which reference population do you use for mortality rate standardisation? (34 countries
concerned)
"Industrialized countries"/                     13
"European population 1976”/
European standard population/
Eurostat population
National census (specify year)                  6
Other 6          include WHO Worod, Population July 1 2000 according to population register. The reference
   population is chosen to match the question or purpose
Balance of population as of 2000 (December, 31) based on the population census as of 2002
Never published standardised mortality rates 1
Several responses                               8
ANAMORT PROJECT January 2008                                                                         Page 50 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Unknown                                          0
G24/ Do you use a correspondence table between ICD-9 and ICD-10 in order to produce aggregated
indicators on causes of death (i.e. indicators on drownings or falls)?
Yes, with a national correspondence table        6
Yes with an external correspondence table        5
No                                               24
Both situations                                  1
Unknown                                          1
No response                                      1
G25/ Is it possible to undertake a multiple cause of death analysis with your database?
Yes                                              21
No                                               17
Unknown                                          0
G26/ If Yes, are you doing multiple cause analysis? (21 countries concerned)
Yes                                              10
No                                               10
Unknown                                          1
G27/ Do you know any study done in your country analysing the under/overestimation of deaths due to
external causes of injury and poisoning? (ESSL 58-65 and ICD-10 S00 -Y98)
Yes                                              4
No                                               28
Unknown                                          6
G27/ If Yes, specify references (4 countries concerned)
Results inconclusive.
Raimo A Lahti. From Findings to Statistics: An assessment of Finnish Medical cause of death information in relation to
                underlying cause coding. Dissertation. Department of Forensic Medicine, Helsinki, 2005.
Soili, Savela-Tapani, Valkonen-Seppo, Koskinen-Hilkka, Ahonen. Multiple cause of death analysis. Tilastokeskus,
                SVT, Terveys 2000:4. Helsinki, 2000.
Not specified
Rooney C, Devis T. Recent trends in deaths from homicide in England and Wales. Health Statistics Quarterly 03, ONS,
                1999.
Rooney C, Griffiths C.Trends in homicides in England and Wales: comparison of death registration and police report
                data. WHOFIC/04.084, 2004.
Griffiths C. The impact of Harold Shipman’s unlawful killings on mortality statistics by cause in England and Wales.
                Health Statistics Quarterly 19, ONS, 2003.
Brock A, Griffiths C. Trends in suicide by method in England and Wales, 1979 to 2001. Health Statistics Quarterly 20,
                ONS, 2003.
G28/ Do you know any study done in your country estimating and/or describing injury related deaths
among the “Unknown and unspecified causes of death” group? (ESSL 57 and ICD-10 R96-R99)
Yes                                              3
No                                               33
Unknown                                          2
If Yes, please give us their approximated/estimated number and specify references (3 countries
concerned)
Glattre, 1980: 7%.
Suicides and unknown causes of death. But the hypothesis, that among the unknown causes, suicide was the most
                frequent cause, was wrong (in fact there are also deaths abroad) and the conclusions do not stand.
G29/ Do you know any study done in your country estimating intentionality in the “Undetermined
intention” group of injury related deaths? (ESSL 65 and ICD-10 Y10-Y34)
Yes                                              2
No                                               32
Unknown                                          4
If Yes, please give us their approximated/estimated number and specify references (2 countries
concerned)
ANAMORT PROJECT January 2008                                                                         Page 51 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
report inquiry on undetermined causes of death.
Brock A, Griffiths C. Trends in suicide by method in England and Wales, 1979 to 2001. Health Statistics Quarterly 20,
                ONS, 2003.
G30/ In your country, may the following persons/institutions have access to an individual death
certificate (in full text, as written by the certifier)?
Anyone
Never, it is not allowed                         30
On approval (ethical, medical                    3
or legal committee)
Always without any needed approval               5
Unknown                                          0
Relatives
Never, it is not allowed                         10
On approval (ethical, medical                    13
or legal committee)
Always without any needed approval               15
Unknown                                          0
Physicians
Never, it is not allowed                         16
On approval (ethical, medical                    12
or legal committee)
Always without any needed approval               9
Unknown                                          0
No response                                      1
Researchers/epidemiologists
Never, it is not allowed                         11
On approval (ethical, medical                    20
or legal committee)
Always without any needed approval               7
Unknown                                          0
Never, it is not allowed                         18
On approval (ethical, medical                    12
or legal committee)
Always without any needed approval               7
Unknown                                          1
Law (police, judges, lawyers)
Never, it is not allowed                         6
On approval (ethical, medical                    23
or legal committee)
Always without any needed approval               9
Unknown                                          0
G31/ In your country, do the following persons/institutions have access to the ICD code(s) of the
cause(s) of death of a specific person as it is stored in the national database (after coding and validation
process)?
Anyone
Never, it is not allowed                         32
On approval (ethical, medical                    5
or legal committee)
Always without any needed approval               0
Unknown                                          0
No response                                      1
Relatives
Never, it is not allowed                         29
On approval (ethical, medical                    8
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"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
or legal committee)
Always without any needed approval               0
Unknown                                          0
No response                                      1
G31/ In your country, do the following persons/institutions have access to the ICD code(s) of the
cause(s) of death of a specific person as it is stored in the national database (after coding and validation
process)? [continued]
Physicians
Never, it is not allowed                         23
On approval (ethical, medical                    14
or legal committee)
Always without any needed approval               0
Unknown                                          0
No response                                      1
Researchers/epidemiologists
Never, it is not allowed                         10
On approval (ethical, medical                    26
or legal committee)
Always without any needed approval               1
Unknown                                          0
No response                                      1
Insurance companies
Never, it is not allowed                         28
On approval (ethical, medical                    8
or legal committee)
Always without any needed approval               0
Unknown                                          1
No response                                      1
Law (police, judges, lawyers)
Never, it is not allowed                         20
On approval (ethical, medical                    13
or legal committee)
Always without any needed approval               3
Unknown                                          1
No response                                      1
G32/ If needed, which type of approval is required to have access to the death certificate or ICD codes
of a deceased (please specify the type of approval according to information requested and person asking
fation)? (35 countries concerned)
Head of statistics offices written permission.
Application only for university or research institutes.
BApproval of privacy commission and national institute of statistics or the regional instance which is collecting the
                  data, for research purposes only.
BIn accordance to the Civil Registration Law and Statistical Law.
CThey need to sign a contract for data protection.
CThere is no exact defined policy.
CDecision of court
Approval for criminal investigation.
Relatives apply via their personal practicing physician. Researchers can have access to death certificates f given
                  approval by the Data Protection Commission.
Scientific institutions licensed by Data Protection.
Researchers: legal-scientific committee. It's necessary to sign an agreement.
The Ministry of Justice gives the approval for access to information.
Official structure takes permission for using integral mortality data.
An application has to be submitted to the Statistical Office where all cases are investigated individually.
Approval of Department of Health and Central Statistics Office (ICD Codes).
Bioethical committee for research purposes.
ANAMORT PROJECT January 2008                                                                         Page 53 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
Physicians or researchers can obtain a death certificate only if they belong to the National Statistical System (members
                of a selected list of Institutes) or they have a special permission from Privacy Guarantor.
Every case needs to be approved by the Legal division according to the national rules of confidentiality statistical data.
Approval of national health director for both full text and coded information of a specific person.
Written request is needed (request and director's Agency agreement).
Legal committee
In order for anyone to obtain a death certificate, he/she must provide the identity card number of deceased, however this
                is accessible to all The certificate obtained is not the original one written by certifier but is called an Act
                of Death. This would contain information as on original death certificate as to causes of death but would
                not contain all other details. However, relatives often obtain original death certificate from certifier.
                This process of obtaining a death certificate is done by the public registry at a charge. If people request
                access to ICD codes, they must come to the department of health information and in this case
                identifiable data is only submitted on approval by ethics, medical or legal committee. In the case of
                insurance companies, the usual process is that they obtain death certificate through the relatives and not
                directly themselves.
With permission (while alive) of deceased for medical research.
Researcher: Ethical committee must recommend the project; Data inspectorate and Health directorate must approve the
                project according to laws and regulations.
Law
An approval from an ethic committee.
Approval of a commission which takes care on data confidentiality is needed in all cases handling with personal data.
                Medical death certificate can be used in a court on the hand of judicial expert. Family members can
                only have a look at medical death certificate stored at the Institute of Public Health of the Republic of
                Slovenia, no copying or photocopying is permitted.
Special laws of the Ministry of Health and the law on individual data protection.
Medical ethics committee approval required for any named data with validated codes.
NB: Never allowed for anyone in 3 countries
G33/ Do you think that confidentiality practices in your country improve/deteriorate the quality of
causes of death statistics?
Improve                                           14
Deteriorate                                       7
No change                                         7
Unknown                                           6
No response                                       4
G34/ In case of a suicide, do you think that rules of confidentiality and/or transparency applied in your
country could lead to under declaration?
Yes                                               9
No                                                24
Unknown                                           5
If Yes, specify (9 countries concerned)
Family, cultural, financial issues.
There is a strong religious prejudice against suicide.
Family issues
Sometimes, relatives do not accept to have this fact on the certificate.
Coroner's verdict is public. Police sometimes reluctant to add extra information to coroner's verdict.
Cases undertaken to be ascertained and so not defined immediately as suicide.
Origin of under declaration: personal problems, family issues and cultural background but not religious.
In Malta, due to small numbers and everyone knows everyone, sensitive issues like suicide are not put down on the
                death certificate. However, information regarding this is also obtained from the police.
Origin of the under declaration: family issues, cultural or religious background.
G35/ Are there pathologies or external causes which are more likely to be under declared for the
reasons of confidentiality in your country?
Yes                                               11
No                                                24
Unknown                                           3
G36/ If Yes, could you name them and explain briefly? (11 countries concerned)
Alcohol related deaths.
ANAMORT PROJECT January 2008                                                                           Page 54 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
AIDS, suicides, overdoses of drugs, neglects and abandonments, maltreatments (Y06-07), medical errors.
Drugs use, HIV, suicides.
Suicides
Alcohol or drug dependence can be under declared with respect to the relatives.
Suicides
AIDS, drug related deaths.
Some of accidental causes of death (i.e. falls before a train) or drug's poisonings are codified as such but could be
                suicides. The certifier has not enough information to define this cause of death.
Alcohol related deaths, suicides, AIDS, however we try to use other sources for these cases.
Suicides possibly due to cultural reasons.
Certifying doctors may not give full information on deaths involving drugs, alcohol, HIV.
G37/ If confidentiality practices can have negative consequences on the quality of causes of death
statistics in your country, what could you suggest or what has been implemented in order to improve
the situation?
Query these cases.
Make sure the application of the confidentiality rules is done correctly. Inform the certifiers about these strict
                 confidentiality rules.
We suggest that the death certificates should be sealed in an envelope and should be sent to the Health Monitoring Unit
                 confidentially, instead of sending it to the Central Population Register and then forwarded to our Unit
                 (current procedure).
It should be possible to compare the mortality data from different sources.
Since 2007, data collection will be transferred to the Institute of Public Health. There are plans to establish a new
                 registry there.
Providing the cause of death information should be limited for statistical purpose and the linkage of hospital and
                 statistical databases would be necessary.
Linkage with other sources could be useful, e.g. since the privacy Law adoption (1999), a lack of information for infant
                 deaths has been registered, these missing information (gestational age, birth weight, etc.) caused a
                 deteriorated quality of causes of death coding.
It could be very useful to obtain complementary information about the investigations done by Justice Ministry or Police
                 and to consider them before defining the ICD code.
Institutional confidentiality, I think, does not have an impact on the quality of causes of death statistics, except the
                 desire of relatives (to certifiers) to suppress the mention of facts publicly in the certificate of cause of
                 death submitted to the registry office (for instance, suicide, alcohol). In e-certificate, there is room for
                 improvement in such situation.
Maybe law allowing identifiable information to be gathered across Europe for medical statistical purposes.
A new Data Protection Low invented in Slovenia in the last years put very strict rules to data protection. As a
                 consequence of this Low, a unit at the Institute of Public Health dealing with health statistics data
                 separated into two parts. Data coding came into a less experienced hands, and quality of coding was
                 deteriorating. With a Transition Facility 2004 Grant project our obligations are also to improve coding
                 by proper organization, enough staff and continuous monitoring.
Short death certificate option without cause of death for the general public.
Drug-related deaths followed up separately with forensic pathologists, specific medical enquiries aimed at potential HIV
                 cases.
G38/ How long are individual death certificates (medical part) kept after coding in your country?
Original paper document
Is not kept                                       1
8 days                                            1
2 months                                          1
3 months                                          2
6 months                                          2
12 months                                         1
15 months                                         1
18 months                                         2
24 months                                         2
36 months                                         1
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"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"
5 years                                          3
10 years                                         2
50 years                                         1
130 years                                        1
Unlimited                                        16
Unknown                                          1
Microfilm
10 years                                         1
Unlimited                                        5
It does exist but unknown duration               1
It does not exist for storage purpose of DC      21
Unknown                                          2
No response                                      8
G38/ How long are individual death certificates (medical part) kept after coding in your country?
[continued]
Digitalized document
3 months                                         1
12 months                                        1
10 years                                         2
Unlimited                                        15
It does exist but unknown duration               2
It does not exist for storage purpose of DC      11
Unknown                                          1
No response                                      5
G39/ In your national database, how are causes of death kept after coding?
Exact words of the physician
Always                                           9
Most of the time                                 1
Sometimes                                        0
Never                                            26
No response                                      2
Summarised words of the physician (29 countries concerned)
Always                                           0
Most of the time                                 0
Sometimes                                        1
Never                                            26
No response                                      2
G39/ In your national database, how are causes of death kept after coding? [continued]
ICD codes
All ICD codes                                    19

Only ICD code for underlying CoD                 11
Other                                            7
No response                                      1




ANAMORT PROJECT January 2008                                                                         Page 56 of 56
"Information included in this document is not an official position of the countries but corresponds to technical information
collected from our network of national experts in mortality and injury"

				
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