Identifying the What, Where and Who for Documenting Key Information on Cause of Death during a Pandemic

As I reported last month, the Pennsylvania Department of Health and County Coroner offices are in a bit of a struggle over their roles and responsibilities to report causes of death, including COVID-19 related causes.  The dispute continues and the issues include:

• How to report the "county location" of the deceased for a COVID-19 related-death?  For example, if the individual became infected while living in Adams County, Pennsylvania, but the final treatment and death was at Penn State Hershey Medical Center in Dauphin County, should the "county of death" be Adams or Dauphin County?
• How to characterize the cause of death?  For example, under Pennsylvania statutory law at 16 P.S. Section 1218-B (2018), County Coroners "shall investigate the facts and circumstances concerning a death that appears to have happened within [their] county, notwithstanding where the cause of the death may have occurred" to "determine the cause and manner of death."  Should a "COVID-19 related death be described as "death by natural cause," a phrase often used on death certificates or more specifically as a "death known or suspected to be due to contagious disease and constituting a public hazard," a phrase referenced in the Coroner's law?  
• Where a patient's attending medical professional certifies the cause of death and reports the cause directly to the State Registrar of Vital Statistics, should the state then be required to share that information with County Coroners?  Attending medical professionals have legal authority to sign death certificates and to make reports directly to the State Registrar under Pennsylvania's Vital Statistics Law of 1953 at 35 P.S. Section 450.101 et seq. (amended in 2012).  Without a clear path for sharing information, how will counties have timely information that can affect other county reporting obligations? 
• Does the State have authority to mandate reporting by the County Coroners using criteria recommended by the federal Centers for Disease Control and Prevention (CDC)? In April 2020, the National Vital Statistics System, which operates under the CDC, issued guidance for reporting COVID-19 related deaths, offering three sample scenarios where the "immediate cause of death" would be described as some form of acute respiratory illness, while COVID-19 would be described as an "underlying cause" that initiated the events resulting in death.
• Who is responsible for resolving any inconsistencies in County and State statistics for deaths, including COVID-19 related deaths?

On a recent WITF-Radio's Smart Talk program in central Pennsylvania, coroners from York County and Cumberland County described their concerns about disparities between state and local statistics.  Charley Hall reported that Cumberland County had 45 COVID-19 related deaths, while the State at the same time was reporting 37 deaths.  In York County, the lower COVID-19 number was reported at the County level, while the State recorded a higher number.  For more on the practical problems, listen to the Smart Talk Podcast for 5/11/2020.  The coroners raised the potential for such discrepancies to trigger erosion of public trust.

In many Pennsylvania counties, as in other states, a significant majority of COVID-19 deaths are occurring in nursing homes or other long-term care residential settings.   Some of the concerns about accuracy and transparency of reporting imply intentional under-reporting or misleading reports regarding deaths in nursing homes.  Pennsylvania has one of the largest populations of citizens in the nation who reside in nursing homes.   Long-term living is a major, multifaceted industry in Pennsylvania.

In addition, the number of diagnosed cases, the location of diagnosed cases, and the number of COVID-19 related deaths can make a difference in whether any particular county is allowed to move away from strict social-distancing related rules.