In the case of death due to alleged medical negligence, it is essential to establish the cause of death as a direct consequence of the alleged deficiency.

In the death certificate, as per the WHO mandated universally followed guide lines, the certifying doctor has to assign (1) the immediate or terminal cause of death, (2) the intermediate or antecedent cause of death, (3) the underlying cause of death and (4) the associate or contributory cause(s) of death.

Judicial versus medical approach
While the judicial thinking in assigning the cause of death is based on the legal principles of proximity of the event and its probability and propensity to cause death, the medical approach in assigning the cause of death is based on the known facts of the disease process so as to identify the underlying cause death.

For instance, take the case of breast cancer that spread ("metastasised") to the thigh bone and caused the bone to fracture ("pathological fracture"). This fracture then liberated fat which entered the blood stream, travelled to the lungs and blocked the flow of blood flow within the lungs. Such a blockage (of blood flow within the lungs) is called "pulmonary embolism" and can cause death from acute respiratory failure.

Cause of death medical certificate
The certified immediate or most proximate cause of death in the above case would be pulmonary embolism.

The intermediate causes of death that were antecedent to the terminal cause would be metastasised cancer and pathological fracture.

The underlying cause of death, that is the basic disease that caused the death, would be breast cancer because this was what was responsible for the sequence of complications that ended fatally.

The reported cause of death in such a case should be breast cancer but, on the other hand, the judiciary might regard pulmonary embolism (the most proximate terminal event) to be the cause death.

Terminal and underlying cause of death
Let us look at another example, that of chronic hepatitis B infection. This disease produces progressive destruction followed by chaotic remodelling of the liver architecture leading to a condition called cirrhosis. The cirrhotic process obstructs blood flowing into the liver and leads to a build-up and increased back- pressure of blood in the veins of the gastro-intestinal system. This in turn causes dilatation of venous channels (varices) in the food pipe. These varices can rupture and result in death from exsanguination, the bleeding itself manifesting as vomiting of large amounts of blood ("haematemesis").

If such a patient dies of bleeding from ruptured varices, the underlying cause of death would be chronic hepatitis B infection. The immediate cause of death would be the actual bleeding itself. Cirrhosis of the liver and esophageal varices would be regarded as antecedent causes that led to the terminal event of bleeding. The cause of death certificate would be as under:

1. Immediate or terminal cause of death ---- Rupture of esophageal varices
2. Intermediate of antecedent cause --------- Esophageal varices and cirrhosis liver.
3. Underlying cause of death ---------------- Chronic hepatitis-B

The underlying disease which in this case is Chronic Hepatitis-B is reported as the cause of death (mortality) as per WHO guidelines.

There are many chronic fatal diseases that progress to a fatal event but the underlying basic disease must be reported as cause of death.

Cascading fatal events in acute, fulminating disease processes
In an acute fulminating condition, the basic disease may cause a cascading sequence of events that may result in death. For instance, septicemia (infection in the bloodstream) can cause complications like disseminated intra vascular clotting, acute respiratory distress syndrome and acute kidney injury. All these conditions are due to diminished tissue perfusion produced by the infection. If more than one bodily system is compromised, the condition is called "multi-organ failure.

Before any treatment has time to be effective, multi-organ failure or even a single system failure may prove fatal. Such complications will be regarded as the immediate cause of death but the underlying cause of death is septicaemia.

Pregnancy related deaths
Deaths during delivery in otherwise normal, healthy women are due to complications like post-partum hemorrhage and amniotic fluid embolism.In the former the uterus does not contract satisfactorily after delivery and in the latter, amniotic fluid enters the blood stream of the mother and causes a cascade of dangerous events. Neither is readily under the control of the attending obstetrician or midwife. The conduct of delivery as the proximate event cannot be regarded as the direct cause of death.

The dichotomy and divergence in judicial and medical thinking in assigning the cause of death is palpably evident in the cases of Jacob Mathew, Martin D'Suoza and Dr. Suresh Gupta. However, the judges graciously accorded credence to the medical approach in these cases. Yet, they did not do so in the case of V.Krihsan Rao versus Nikhil Superspeciality Hospital. The latter is a classical example of how a ruling in a case of alleged medical negligence results in gross injustice; yet, consumer forums unfortunately tend to consider this as an index case as it is closer to their line of thinking.

Clear guide lines need to be framed.

Written By: Dr.Shri Gopal Kabra, MBBS, LLB, MSc, MS(Anatomy), MS(Surgery)
15, Vijay Nagar, D-block, Malviya Nagar, Jaipur-302017
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