The final referral: A 1-year retrospective review of death referrals through the lens of forensics
DOI:
https://doi.org/10.7196/SAMJ.2025.v116i3.3644Keywords:
Autopsy, Cause of Death, Forensic Pathology, Unnatural Death Referrals.Abstract
Background. Under South African (SA) law, all unnatural, sudden and unexpected deaths, as well as procedure-related deaths, must be reported to the SA Police Service and referred to the Forensic Pathology Service (FPS). In the Western Cape Province, referrals to FPS require completion of the FPS100 form by a senior medical practitioner.
Objective. To assess the appropriateness, completeness and legibility of FPS100 referral forms submitted to Tygerberg Forensic Pathology Services over the course of 1 year in the Western Cape Province, and to evaluate whether the suspected presumed cause of death was in line with the World Health Organization’s standards.
Methods. This was a cross-sectional retrospective review of all FPS100 referral forms submitted to the Tygerberg Forensic Pathology Mortuary over 1 year. An experienced forensic pathology medical practitioner reviewed the appropriateness, completeness, legibility, commissioning status and accuracy of presumed cause-of-death classifications reflected on the FPS100 referral forms received.
Results. Of the 1 252 cases accompanied by a referral form, 81.6% were deemed incomplete, with 22.3% uncommissioned, rendering them inadmissible in court. Even though most of the referrals were legible, over 43% indicated misclassified formulations of the presumed causes of death.
Conclusion. The study revealed significant deficiencies in FPS referrals, including incomplete or uncommissioned forms and frequent misclassification of presumed causes of death. These shortcomings undermine the legal validity of the referral forms, and may delay medicolegal processes and even result in direct subpoenas to referring medical practitioners. The findings highlight the urgent need for strengthened training for medical practitioners across all levels of experience, and for the implementation of standardised referral protocols. Equally important is enhancing awareness of the medicolegal value of FPS involvement, and the critical impact of accurate, high- quality referrals.
References
1. South Africa. Births and Deaths Registration Act No. 51 of 1992. https://www.gov.za/sites/default/files/ gcis_document/201409/a511992.pdf (accessed 5 March 2023).
2. South Africa. National Health Act No. 61 of 2003. https://www.gov.za/documents/national-health-act (accessed 5 March 2023).
3. South Africa. Inquests Act No. 58 of 1959. https://www.gov.za/sites/default/files/gcis_ document/201505/act-58-1959.pdf (accessed 5 March 2023).
4. South Africa. Health Professions Amendment Act No. of 2007. https://www.gov.za/sites/default/files/ gcis_document/201409/a29-07.pdf (accessed 5 March 2023).
5. National Department of Health, South Africa. Regulations regarding the rendering of forensic pathology services. Pretoria: NDoH, 2018. https://www.gov.za/sites/default/files/gcis_document/201 803/41524rg10811gon359s.pdf. (accessed 5 March 2023).
6. Western Cape Department of Health. Circular H146 of 2020: Requirements for the admission of decedents that died of unnatural causes from healthcare facilities to Forensic Pathology Service. Cape Town: Department of Health, 8 July 2020. https://www.westerncape.gov.za/dept/health (accessed 1 December 2023; available as Appendix).
7. Saayman G. South Africa: Vulnerable persons and groups in a vulnerable democracy – can forensic medical services help to ensure justice in critical times? Acad Forensic Pathol 2017;7(3):434-443. https://doi.org/10.23907/2017.036
8. Walker S. Capturing health information: A perspectives paper. Health Inf Manag J 2006;35(3):13-22.
9. DeJongJA.InvestigatingtheeffectivenessandefficiencyofforensicpathologypracticeintheWestern Cape, South Africa. Master’s thesis. Cape Town: University of Cape Town, 2017. http://hdl.handle.
net/11427/24882 (accessed 21 February 2023).
10. Burger EH, Groenewald P, Rossouw A, Bradshaw D. Medical certification of death in South Africa – moving forward. S Afr Med J 2015;105(1):27-30. https://doi.org/10.7196/samj.8578
11. Moodley S, Govender K. A survey of perioperative clinician’s knowledge and application of the law regarding the classification of deaths in the perioperative period. S Afr J Anaesth Analg 2019;25(3):10-15. https://doi.org/10.36303/SAJAA.2019.25.3.2223
12. Burger EH, van der Merwe L, Volmink J. Errors in the completion of the death notification form. S Afr Med J 2007;97(11):1077-1081. https://pubmed.ncbi.nlm.nih.gov/18250917/ (accessed 17 March 2026). 13. Qaddumi JAS, Nazzal Z, Yacoub A, Mansour M. Physicians’ knowledge and practice on death certification in the North West Bank, Palestine: A cross-sectional study. BMC Health Serv Res
2018;18(8):1-6. https://doi.org/10.1186/s12913-017-2814-y
14. Nojilana B, Groenewald P, Bradshaw D, Reagon G. Quality of cause of death certification at an
academic hospital in Cape Town, South Africa. S Afr Med J 2009;99(9):648-652. https://pubmed.ncbi.
nlm.nih.gov/20073291/ (accessed 23 March 2026).
15. Department of Home Affairs, South Africa. Cause of death certification: A guide for completing
the Notice of Death/Stillbirth (DHA-1663). Pretoria: Department of Home Affairs, 2012 (accessed
5 March 2023).
16. World Health Organization. International guidelines for certification and classification (coding) of
COVID-19 as cause of death. Geneva: WHO, 2020. https://www.who.int/publications/i/item/WHO-
2019-nCoV-mortality-reporting-2020-1. (accessed 16 May 2025).
17. Cullinan K. Health services in South Africa: A basic introduction. Health-e News, 29 January 2006.
50 April 2026, Vol. 116, No. 3
https://health-e.org.za/2006/01/29/health-services-in-south-africa-a-basic-introduction/
(accessed
16 May 2025).
18. Saukko P, Knight B. Knight’s Forensic Pathology. 4th ed. Boca Raton: CRC Press, 2015.
19. South Africa. Criminal Procedures Act No. 51 of 1977. https://www.justice.gov.za/legislation/
acts/1977-051.pdf (accessed 5 March 2023).
20. Ranchod S, Adams C, Burger R, et al. South Africa’s hospital sector: Old divisions and new developments.
S Afr Health Rev 2017;10(3):101-110.https://hdl.handle.net/10520/EJC-c80f3c5a8 (accessed 23 March 2026). 21. Caldwell RI, Aldous C. The National Health Insurance, the decentralised clinical training platform, and specialist outreach. S Afr Med J 2016;107(1):39. https://doi.org/10.7196/samj.2016.v107.i1.12008 22. Ahmed N, Davids R. COVID-19: Are South African junior doctors prepared for critical care management outside the intensive care unit? Pan Afr Med J 2021;40(41). https://doi.org/10.11604/
pamj.2021.40.41.30134
23. Hatcher AM, Onah M, Kornik S, et al. Placement, support, and retention of health professionals: National, cross-sectional findings from medical and dental community service officers in South Africa. Hum Resour Health 2014;12(1):14. https://doi.org/10.1186/1478-4491-12-14
Downloads
Published
Issue
Section
License
Copyright (c) 2026 S van der Merwe, I Mentoor, N-K Mould-Millman, J Verster
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Licensing Information
The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Publishing Rights
Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.
