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Clostridium Difficile Deaths

Last Updated 7 August 2009

Clostridium difficile (C.diff)

This section presents information on the numbers of deaths for which Clostridium difficile was mentioned on the death certificate.

Why these figures must be used with caution

In its "Report on Review of Clostridium difficile Associated Disease (CDAD) cases and Mortality in all Acute Hospitals in Scotland …" (published on 7 August 2008), Health Protection Scotland (HPS) wrote that:

"… four NHS boards undertook detailed case note reviews …. [and] … found marked discrepancies between the General Register Office for Scotland (GROS) data and the actual cause of death." 

The discrepancies were due to the way in which the death certificate was completed.  Most arose because:

• the death certificate mentioned Clostridium difficile when (in the investigators' view) it should not have done so - (e.g.) "24 should not have had CDAD on the death certificate in any category"; or
• the death certificate mentioned Clostridium difficile in what the investigators believed was the wrong place - (e.g.) "in 5 of 6 cases where CDAD was reported as the underlying cause of death, it should have been a contributory factor".  

The report also referred to "3 cases where CDAD appeared in the GROS codes [but] was not on the original death certificate stub". A review of these cases at GROS showed that Clostridium difficile was indeed mentioned on the death certificate - but must not have been noted on the stub, which is intended to provide a summary of what was recorded on the death certificate. 

GROS's coding of the causes of death is based on the information on the death certificate. If Clostridium difficile is mentioned on a death certificate when it should not have been, the number of Clostridium difficile deaths will be over-estimated. Therefore, these figures must be used with caution.

Following the Health Protection Scotland investigation in 2008, which was commissioned by the Scottish Government, some Health Boards reviewed or revised their guidance to doctors regarding the completion of death certificates. This was done in order to reduce the number of occasions on which Clostridium difficile is mentioned in the wrong part of the death certificate, or is mentioned when it was not a cause of death. This change in recording practice will lead to a break in the series of statistics on Clostridium difficile associated deaths: statistics for 2008 will not be directly comparable to those for 2007 and earlier years, nor to those for 2009 and later years.

Why there are differences between some of the figures which are published

There are a number of reasons why there may be differences between the figures which are produced by different bodies, or are published at different times.

First, because a range of information is available from the death certificate (as described on the "Death Certificates and Coding the Causes of Death" page), figures for Clostridium difficile can be produced on the following bases:

• "underlying cause" - cases where Clostridium difficile was the cause which initiated the chain of morbid events leading directly to death;  
• "contributory factor" - cases where Clostridium difficile was not the underlying cause of death, but it did contribute to the occurrence of the death - e.g. it did not cause the death, but may have hastened its occurrence; and
• "any mention" - i.e. clostridium difficile either appeared to be the underlying cause of the death, or was just a factor which was thought to have contributed to, or hastened, the death.

Second, when coding deaths, GRO applies the rules of the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). The complexity of these rules can result, in some cases, in the cause of death coded by GROS differing from that which a health board would choose. Some further information about this is given in the definition of the basis of the Clostridium difficile figures which can be found on the "Clostridium difficile Deaths - the Coverage of the Statistics" page.

Third, GROS's normal practice is to count deaths on the basis of the area of usual residence of the deceased rather than of the place of occurrence of death. (When the person's usual residence is outwith Scotland the place of occurrence is used). Therefore, the number of deaths for (say) a health board area is normally the number of deaths of residents of that area (plus the small number of deaths of people from outwith Scotland which occurred in that area). However, figures for Clostridium difficile deaths can also be produced on the basis of the health board which contains the hospital in which the death occurred (with people who died at home being counted as "non-hospital" deaths). For some health boards, the two sets of figures will differ, due to residents of one area having died in hospitals in another area.

Tables

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