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More than seven years ago, a Victorian doctor embarked on what has become a quest to correct a small administrative quirk that has made the state’s death certificates unreliable. By Michael Winkler.
Why Victorian death certificates are unreliable
In the words of broadcaster Edward R. Murrow: “The obscure we see eventually. The completely obvious, it seems, takes longer.” In Dr Sarah Charlton’s experience with Victoria’s Registry of Births, Deaths and Marriages, it’s about seven years and counting.
As a doctor and palliative care specialist in a major Victorian hospital, Charlton signs or oversees more than a thousand death certifications each year. Every one of these online submissions, she says, is potentially inaccurate.
In Victoria – and in no other Australian state – in the Medical Certificate of Cause of Death (MCCD) it is mandatory for the certifying doctor to provide a specific time duration for medical conditions connected to or contributing to the death. Charlton argues this length of time is often unknown, forcing doctors to guess.
“All death certificates in Victoria are unreliable,” she says. “On the MCCD you need to state the cause of death, then the form asks for antecedent causes, conditions that led to the primary cause of death. For example, cholesterol, high blood pressure, diabetes. It also asks for contributing causes. These are things making you more likely to die of the primary cause because you are less well, for example chronic kidney disease.”
Doctors usually know the duration of the primary cause of death but can rarely ascertain that of other conditions. “No one ever knows exactly how long they’ve had high blood pressure or type 2 diabetes,” she says. “But the Victorian system mandates specifying a duration for all those causes of death.”
Medical records typically don’t include that information. And at the time of death, no one wants to grill a bereaved family for exact details of the deceased’s medical history.
“Some doctors, who are overworked and rushed, pluck a number out of the air for duration of underlying conditions,” Charlton says, or they leave those conditions off the form altogether to avoid having to make up a duration, “and sign their name to something they know is wrong. Guessing a number might not seem that big a deal, but it can have ramifications down the track,” she says.
Things weren’t always this way. When Charlton started her medical career, the death certificate was an A3 form with space to write whatever was required, including estimates of illness duration with appropriate caveats. “It was always recognised that you would use your best clinical judgement to make an assessment based on information that you had,” she says.
That all changed almost a decade ago, when the documentation was brought online, and with it, the field specifying duration.
The solution Charlton landed on was to ask that the field on the online form be toggled, to make it non-mandatory.
There began a journey. Charlton raised the issue with the Registry of Births, Deaths and Marriages Victoria (BDM) in 2018. As well as numerous emails, she met with BDM staff in person, presenting an anonymised slide deck of real-life examples from the span of several weeks at her busy hospital, each demonstrating the inappropriateness of the time mandate.
She has extensive records of email correspondence with BDM’s medical team, the legal team, the data team, a general manager and an acting director.
In one of their responding emails, BDMV acknowledged the problem and said it would look at solutions and present options to the registrar. No progress was made.
In December last year, Charlton received another email response from the registry stating: “Changes to BDM’s core system would involve a cost and be time-consuming. While such a change is always possible, data quality must be balanced against other considerations.”
The same email noted, “We can currently accept causes of death with a ‘zero unit’ duration to indicate unknown, but I’m unsure how many medical practitioners do this.”
Charlton responded with the obvious point that such a time designation would be untrue. “You cannot have anything for ‘zero time’, this means you didn’t actually have it. This is a legal document that we sign our names to, so not something that should knowingly contain untrue statements.”
She also approached state and national bodies, her local member of parliament and Victoria’s attorney-general. (BDM was previously part of Victoria’s Department of Justice and now sits within the Department of Government Services.)
At one point in their protracted correspondence, the registry told Charlton the change could not occur because it would contravene the requirements of the Australian Bureau of Statistics (ABS). She countered that the opposite was in fact true, because incorrect inputs were corrupting ABS data. In February she met with BDM staff, alongside a senior ABS manager, to explain that the proposed change is aligned with ABS best practice.
Just under 90 per cent of Australian deaths are doctor certified, with the remainder going to the coroner. The ABS publishes provisional mortality figures monthly and causes of death annually, aggregating and analysing data from MCCDs.
ABS guidelines for death certification state: “Where the exact time or date of onset is not known, the best estimate should be made … A precise numeric measurement is not required if not known ... If the duration of a condition cannot be ascertained writing ‘unknown’ is acceptable.”
The ABS wondered why Victoria had a disproportionate number of single causes of death with no antecedent or contributing causes. “It is because doctors are worried about signing their name to something they know is false,” says Charlton. “But where that data is being collected, it is inaccurate and unreliable, which has public health implications: rubbish in, rubbish out.”
The president of the Australian Medical Association Victoria, Dr Simon Judkins, also wrote to BDM in August seeking reform but has not received a response. “The current duration requirements lead to omissions or guessed entries that undermine the accuracy of Victoria’s mortality data, reducing its value for epidemiology, public health surveillance and resource allocation, with separate consequences also arising for legal processes such as probate and capacity decisions,” Judkins tells The Saturday Paper.
Charlton has seen these consequences play out. “I know of a well-meaning doctor who made a guess and said that someone had dementia for 15 years, but the person had made a will 10 years before they died. Suddenly, probate was in question because there were issues around the capacity of the person who died to make a will.
“What also frustrates me about this process is that they (BDM) tried to make out that it was just my problem – just me, my team or my hospital, because they said they hadn’t heard from anyone else – but it is a systemic problem,” Charlton says. “We are being told that the future of health is in everything digital, and we don’t even have control over this tiny thing. It doesn’t seem responsible, and it baffles me.”
In May, in response to another enquiry, Charlton received an email from a senior BDM manager saying, in part: “We’re currently scoping out system change options and the costs associated … We’re hoping over the coming weeks to finalise the proposed options and be in a place to present our recommendations to move forward.”
Those weeks passed. Nothing happened.
Heightening Charlton’s exasperation is occasional proof that BDM’s online system is not immutable. Several years ago, a required field “Name at Birth” was introduced to the MCCD system. After pushback, that field was made non-mandatory.
Last week, medical practitioners were informed there was a scheduled outage for the MCCD site because, “We’re working to improve our online system based on your feedback.” This is in line with BDM’s Customer Service Charter, which claims, “We remain focused on how we can continuously improve our services” – a promise not borne out in this circumstance.
Births, Deaths and Marriages did not respond to The Saturday Paper’s requests for comment, nor did the Department of Government Services.
Apart from the implications for public health data and the concern that doctors are signing their names to unverified or unverifiable statements, this is also a story about the blunt instrument of bureaucratic non-responsiveness.
If someone with Sarah Charlton’s expertise, at the heart of the system, can devote years of effort and still fail to get a public registry to change a small piece of software code – what hope is there for citizens with less personal and professional power? The solution to this specific problem seems simple, and yet the experience has been Kafkaesque.
“It’s so frustrating,” she says. “I’ve said to my husband, if I get this fixed, I’ll die happy, and at least my death certificate might be accurate.”
This article was first published in the print edition of The Saturday Paper on December 6, 2025 as "Poor form".
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