Between 2009 and 2012 (the evaluation period) 127,545 cases of death were registered in Berlin, while 111,457 cases were registered in Brandenburg (239,002 cases total). A death certificate (in accordance with the burial laws of Berlin and Brandenburg) had to be issued by a physician for each of the deceased. Due to the legislative powers of the federal states of Germany, each state bears responsibility for regulating burial and post-mortem examination laws. Thus, there are significant differences between Berlin and Brandenburg's burial and post-mortem examination laws. Unfortunately, an unknown number of death certificates were issued by EMS emergency physicians. EMS emergency physicians are often caught in a conflict of obligations between their guarantor position (to save the patient's life and health), the police and criminal investigation department's possible interests, and the health authority's interests. These conflicts might eventually lead to fine/penalty proceedings with the health authority. To determine the relevance of fine/penalty proceedings, all 12 local health authorities in Berlin and 18 local health authorities in Brandenburg were asked to complete a structured questionnaire regarding fine/penalty proceedings in the context of post-mortem examinations and/or the issuance of death certificates between 2009 and 2012. Within the evaluation period, only 15 fine/penalty proceedings were conducted (nine in Berlin and six in Brandenburg), which equals 0.0062 % of all cases of death in Berlin and Brandenburg. Serious shortcomings regarding post-mortem examinations were not found in this study, as only one emergency physician was affected in each state. Our results show that the emergency physician's fear of being subjected to legal action due to incorrect certificates of death is currently minor. Nevertheless, the study in part revealed serious structural issues in regard to the execution of post-mortem examinations. It also shows that fine/penalty proceedings are not an appropriate means to assure quality, as health authorities can usually only formally review death certificates.
