Child Drowning

In high-income countries (HICs), before a body can be buried or cremated the death must be reported
and a formal death certificate issued. There are incentives to be derived from following that course of
action, which play a large part in the relative success of reporting systems. For example, in order to
receive death benefits from an insurance policy or a government social security programme, an official
death certificate is required. This can only be received by a family if the death has been reported. In
LMICs, on the other hand, there are no incentives to reporting the death; in fact, there are a number of
disincentives to reporting, as outlined above.
1.4 A CLASSIFICATION SYSTEM UNSUITABLE FOR LMICS
Lack of contact between a family member who has knowledge of the death of a child and the health
system is the primary reason for under-reporting drowning. However, in cases where a family member
does report the drowning death, the place of report usually lacks the capacity to classify the death
appropriately. In LMICs, which are predominantly rural, the village clinic or equivalent facility is the
lowest level of the health system. The staff at this lowest level where almost all drowning occurs lack
the necessary training to use the International Classification of Diseases (ICD) reporting system 6 which is
mandated by WHO for national reports of death.
The ICD system was developed in HICs for use in HICs. ICD coding staff usually require years of training,
with completion of courses in medical anatomy, medical vocabulary, medical terminology, surgical
procedural terminology, forensic and medico-legal issues. Trainee coders complete internships before
being certified. Coders often specialize in specific types of medical coding due to the complexity of the
system. Many HICs have professional bodies to certify the training process and provide continuing
education with periodic re-certification due to updated classifications in the ICD, which occurs as often
as every year.
In HICs the classification system is effective because coders are trained and supervised to classify the
many different causes of death using death certificates, hospital discharge reports, coronial systems and
other systems tied to governmental structures. These systems record numerous details of the
circumstances surrounding the drowning death, which facilitates correct classification. However, even
with all the resources and training available in HICs, there is abundant evidence that the complexity of
the system lends itself to substantial problems with performance as noted by many authors. 7
In HICs, well-trained coders are available at each level of the system, from the specialty hospitals at the
top tier down to the facilities at county and city level. There is usually a coroner or medical examiner at
each level of the health system as well. No matter where a death occurs or is reported, there is a trained
specialist to provide the correct coding details. There is also a supervisor with the same training to
provide quality assurance. In contrast, in LMICs the facilities staffed with individuals trained and
6
The International Classification of Diseases (ICD) dates from 1893 when a classification scheme was adopted based on the
system used by the City of Paris, which was itself based on English, German and Swiss systems. The system continued to be
administered by the French Government until 1928 when it became a process of the Health Organization of the League of
Nations. In 1948 it became a United Nations process with the advent of the World Health Organization and has continued to
evolve into an increasingly complex taxonomic system as medicine has advanced. The ICD is published by WHO to standardize
collection, processing and presentation of health conditions. New versions occur about every 10 years, with minor updates every
year and major updates about every 3 years.
7
Hunt, P. R., et al. (December 2007). ‘Completeness and accuracy of International Classification of Disease (ICD) external cause of
injury codes in emergency department electronic data’. Injury Prevention, 13(6):422-425; Schwartz, R.J. et al. (July 1995).
‘Accuracy of e-codes assigned to emergency department records’. Academic Emergency Medicine, 2(7): 615-620; Lu TH, et al.
(2007). ‘The proportion of injury deaths with unspecified external cause codes – A comparison of Australia, Sweden, Taiwan and
the US’. Injury Prevention, 13(4):276-281; McKenzie, K., et al. (February 2009). ‘Accuracy of external cause-of-injury coding in
hospital records’. Injury Prevention, 15(1):60-64; Bhalla K, et al. (November 2008). ‘Estimating the distribution of external causes
in hospital data from injury diagnosis’. Accident Analysis and Prevention, 40(6):1822-1829.
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