Dr Andrew describes a case where a cause of Death may not be the Cause of Death
In many cases, cause of death is not exactly shrouded in mystery. This “common knowledge” can be deceiving however, and much mischief can be done in legal proceedings by purported experts conflating a cause of death with the cause of death.
The following example illustrates the concept.
A 68-year-old man is struck by an automobile while getting his mail from his roadside mailbox, sustaining multiple fractures, lacerations of the liver, traumatic brain injury and a high spinal cord contusion leaving him with quadriplegia (paralysis from the shoulders down). His medical history includes diabetes, high blood pressure and coronary artery disease.
After undergoing multiple surgeries, he is transferred to a long-term care facility where he dies nearly three years later. The death is appropriately reported to the medical examiner who performs a record review and certifies the death as “complications of multiple blunt impact injuries.”
The family of the deceased files a wrongful death suit against the driver of the automobile, claiming that but for the injuries, death would not have occurred when it did.
The medical examiner’s record review may or may not have been sufficient to support the certification of death as due to trauma, but it should not be taken at face value. Had an autopsy been performed and revealed a hypertensive stroke or myocardial infarction due to atherosclerotic obstruction of a coronary artery, the causation aspect of a wrongful death lawsuit would be called into question.
Absent an autopsy, the only alternative for one defending against the suit as well as the prudent course for the plaintiff, is seeking a competent expert review of the records made available to the medical examiner.
Possible outcomes include the following:
- Both plaintiff and defense experts agree with the medical examiner.
- One or the other expert opines insufficient records have been made available for review and thus a reliable opinion cannot be expressed.
- The defense expert, citing fever, cough, increasing white blood cell count and an infiltrate on chest x-ray, opines that the cause of death was pneumonia and thus is unrelated to the trauma.
- The defense expert, citing acute onset of chest pain, electrocardiogram changes and rapid deterioration to cardiac arrest, opines the cause of death is myocardial infarction due to long-standing arteriosclerotic cardiovascular disease and thus is unrelated to the trauma.
The first two outcomes speak for themselves but the third and fourth warrant comment.
The expert in outcome three has, more likely than not, erred in that pneumonia is a common and quite predictable complication of the debilitated state stemming from the decedent’s previous trauma. Pneumonia can be a cause of death, but in this case is not the cause of death.
The expert in outcome four may be on to something. The decedent was known to have coronary artery disease and the circumstances of his death are more consistent with a sudden cardiac event than the accumulation of various complications of his trauma over time. The opinion cannot be 100% certain, but definitely casts doubt on the assumption that trauma was the cause of death.
How so? Cause of death is the disease, injury or their combination that initiates an ultimately lethal train of events, unbroken by a competent intervening cause of death, and without which death would not have occurred. Pneumonia, as a known complication in this scenario does not suffice as a competent intervening cause.
Myocardial infarction, on the other hand does. The take-away message is that whether plaintiff or defense, the attorney handling such a case should always opt for a thorough medical review, especially in fatal cases that do not offer autopsy confirmation of the certified cause of death.
