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Three children died in the paediatric intensive-care unit or emergency department. The case of a 3.5-year-old girl who died after a pneumococcal infection was considered a natural death. An 8-year-old boy suddenly collapsed and died despite resuscitation. The attending physician considered this an unnatural death. The district medical examiner, after consulting the district attorney, required an autopsy, but the cause of death could not be ascertained and the next of kin were to be examined for cardiac rhythm disorders. A 2-year-old boy died after a fall out of a window. The district medical examiner and the district attorney concluded that there was sufficient explanation for this unnatural death and that autopsy was not necessary. The attending physician has several important tasks around the time of and after death in which he or she is subject to a number of legal regulations. Knowledge of these regulations is mandatory for good medical practice.

The assessment of the manner of death by physicians is often a problem due to unclear regulations on this point. By means of a questionnaire we investigated how 40 nursing home physicians assess the manner of death in 14 different hypothetic cases and whether the physicians should report the case to the medical examiner if confronted with similar cases in practice. Some cases of unnatural death would not be reported. Especially in cases of death after a collum fracture the law and medical practice diverge. The reasons to report or not to the medical examiner were also investigated. Death fitting in the 'descending line of life' was most mentioned.

'Cause of death' is an ambiguous concept. Terms such as 'immediate', 'underlying' or 'primary' cause of death are used, along with indications such as 'associated conditions' and 'contributing factors'. Furthermore, the terms 'mechanism', 'manner' and 'method' of death are used internationally. The Dutch classification of the manner of death with just two categories (natural and unnatural death) is not used in other countries. Belgium, Germany, England and the USA use more or other categories. It is recommended that the Netherlands consistently use these terms in accordance with the international codes for both the death certificate as well as the registration form for the cause of death statistics. The circumstances of death of which the medical examiner needs to be notified should be explicitly stated on the death certificate.