Recommendations for Completing Death Certificates

The SUDC Scientific Advisory Board offers the below recommendations when completing Death Certificates in cases of Sudden Unexplained Death in Childhood (older than 12 months of age). Resources, such as the National Association of Medical Examiner's guidelines for investigating SUID were utilized for their creation.   

If a properly conducted investigation and autopsy discloses a lack of findings, we recommend reporting the cause of death in Part I and 2 of the cause-of-death statement on the Death Certificate as:

SUDC or undetermined (Both will most likely receive ICD-10 code of R-99 for "other ill-defined unspecified causes of mortality". However the use of "SUDC" infers an unexplained non-suspicious thorough investigation, whereas "undetermined" can infer many scenarios including an incomplete or supicious investigation.) We recommend the following for subsequent sections of the Death Certificate:

Example: History of febrile seizures (if known, include lifetime quantity and date of last FS)

Manner Of Death: Undetermined (or natural depending on comfort of pathologist)

"Describe How Injury Occurred" box: If nothing concerning in the history, scene, autopsy, records, etc. then include "No injuries or other external stressors identified after complete autopsy and investigation."

Autopsy Considerations in SUDC

Determining the cause and manner of death when an infant or young child dies suddenly and unexpectedly requires a thorough investigation and can be some of the most difficult and frustrating cases that the medicolegal investigation team will face. Examination of the scene where the infant/child died, performance of a complete autopsy, and a review of the child’s and family’s medical history are the three critical elements that will give the medicolegal investigation team valuable knowledge to assist in determining how and why the child died.

Due to the rarity of these tragedies after one year of age, even in populated areas, we offer the information below to assist you in focusing your autopsy in areas that our research has found the most provocative findings to date. SUDC research has already evaluated the medical records and slides of over 160 children who died suddenly where the cause of death was not clear to the attending pathologist. The items listed below are indicated by our completed reviews of these children.

  • Representative sections of brain including
    • Bilateral hippocampus (include gross description of symmetry)
    • Temporal lobe cortex near hippocampus
    • Midbrain
    • Pons
    • Rostral medulla
    • Cerebellum including dentate
    • Basal ganglia
    • Watershed cortex
  • Thymus
  • Gastro-esophageal junction for signs of GER

Nueropathology services, including MRI, are available through the SUDCRRC. If this is not an option, retain as much brain tissue as possible in formalin.

  • Blood, bile and urine spots for metabolic testing
  • Blood in EDTA for genetic anakysis when indicated. (The SUDCRRC also provides genetic specimen kits that can be made available to ME/C offices)
  • Urine and/or blood for toxicology
  • Vitreous electrolytes, VUN, creatinine
  • Microbiology specimens for culture/PCR when indicated
  • Fresh frozen tissue without preservatives for further metabolic and/or genetic studies

Radiographs and photographs as indicated.

Scientific Advisory Board

Dominic Abrams, MD, MRCP
Michael J. Ackerman, MD
Thomas A. Andrew, MD, FCAP, FAAP
Andrew M. Baker, MD
Professor Roger Byard, MD
Orrin Devinsky, MD
J.C. Upshaw Downs, MD
Thomas Keens, MD
Joanne Kuntz, MD
Kelly C. Lear-Kaul, MD
Peter Lin, MD
Deborah A. Robinson
Gregory Webster, MD, MPH
Ross Reichard, MD


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