Death registration created more difficulties for the registrars than any other aspect of their duties. The old parish registers sometimes recorded burials and the cause of death; but many recorded only the burials of parishioners where the parish 'mortcloth' (the pall used to cover the body) was hired. Even where burials were regularly recorded, they did not include people who were not buried in the parish kirkyard. Causes of death in the old registers often followed traditional rather than medical descriptions. The Scottish Poor Law provided poor people with the free services of a parish doctor and in the cities this service was widely used, but effective drugs were few and doctors' skills were limited. Even a conscientious doctor might visit a patient only once, give what treatment he could, and leave it at that. In a society where the deaths of babies and young children were commonplace, it seemed pointless to summon the doctor to a deathbed. In remote parishes there were few doctors, and obtaining a death certificate from a medical man was even more difficult. The causes of death in the old registers often referred to ailments by traditional names, and were written down as given by the family of the deceased. In the registers of Edinburgh, 'bowel hive' or 'bole hive' frequently appears as a cause of death amongst infants, although it was not a medically recognized term. It referred to almost any gastric symptoms.
The Disruption of the Church of Scotland created problems for death registration as it did for many other aspects of Scottish vital statistics. Free Churchmen continued to bury their dead in the parish kirkyard, and in northern communities where the Free Church was strong, they often did so without reference to the minister or the session clerk, as noted by one of the registration examiners in the early days of registration:
'Unfortunately it often happens that there are no Church Officers; and even when there are, parties frequently break open the gate, dig the grave, and bury the dead, in spite of all opposition.'
The need for accurate death reporting was one of the chief motivations for state registration. Death statistics were the basic tool of public health, but proof of death was important for legal purposes, and sudden or unexplained deaths aroused suspicions of foul play. In England, it was not at first compulsory to report births to the registrar even after state registration was introduced. In cases of death, the English Registration Act was rather vague. Those present at a death, or in the house, when someone died, were expected to report the death within eight days, but no penalty was imposed for failing to do this. As in the case of births, the registrar was expected to make his own inquiries. The English law relied on the clergy, undertakers and sextons, who could be fined up to £10 if they buried a body without a certificate of death registration being produced. By the time the Scottish Registration Act was passed, this system was felt to be most unsatisfactory, particularly for recording infant deaths. Although there were immensely strong social pressures to bury the dead with due formality, desperately poor families, and particularly unmarried mothers, might be tempted to dispose of infants' bodies without ceremony. No clergyman or undertaker would be used, and the death would not be recorded. This gave rise to much anxiety about the possible level of infanticide in Britain. Even when a death was reported to the registrar, the English law did not require the death certificate to be signed by a doctor, though all recognized medical men were given blank forms for the purpose. The English, too, could use the free services of a Poor Law doctor, and it was becoming more common for doctors to write death certificates; but very young children, and old people with chronic conditions, were neglected groups.
The Scottish Registration Act tried to avoid these problems by making it compulsory for the Scottish people to report a death. A strict order of responsibility was laid down in the Act, falling first on relatives present at a death, then on the landlord or anyone else in the house, and, if the death occurred in the open, on anyone discovering the body. The penalty for failing to report a death was a fine of 20 shillings, which went up to 40 shillings for a failure to respond to a request for information by the registrar. The Scottish Act also required any doctor who had seen the deceased person in the months before death to provide a certificate within ten days of the death, under penalty of a 40 shilling fine. This, of course, did not end the problem of incomplete reporting of causes of death, since many people had not seen a doctor at all.
This page of an early statutory death register for Stornoway, on the Isle of Lewis, shows the incomplete nature of early registration. An illegitimate baby aged three months, without a recorded Christian name, has died of an unspecified cause, and no medical attendant ever saw her. An elderly woman has died of a vaguely defined 'palsy', without a doctor having seen her, and her death was reported to the registrar by a nephew not present when she died. The local procurator fiscal (the Crown prosecutor) has investigated a case of accidental drowning, as he was legally obliged to do; but the registration examiners of this period often complained that the procurators took little trouble in such cases, since they had limited funds for this purpose. The examiner for the Isles was convinced that it was easy for Highlanders to get away with murder!
In cases where a doctor had specified the cause of death, he might not have seen the deceased for a considerable time before they died, and was simply assuming that the illness he had been called to treat was also the cause of death. Doctors could also write death certificates without examining the body - or even checking that the person was actually dead! The law was very unpopular with the medical profession, who were not paid for issuing death certificates, and who did not like certifying the death of a person they had not seen for some months. Their protests led to some relaxation of the law in 1860. After that, a doctor was fined only if he refused to respond to the registrar's request for a certificate. Few doctors were ever penalized in this fashion, and it was probably the medical profession's growing interest in maintaining accurate death statistics, rather than fear of fines, which motivated them to take more care over death registration. Nevertheless, the Scottish law did assist in a general movement towards more accurate death reporting, and the English law was changed in 1874 to bring in similar compulsory measures for reporting a death.
By the end of the century, death recording was still causing concern on both sides of the border. Adult deaths were better recorded than in the past, but many infant deaths were still not certified by a doctor. A Parliamentary Committee in 1893 investigated death certification throughout Britain, and found that while the Scottish cities now had a very high level of medically certified deaths - around 97% in Glasgow, for instance - in the Highlands and Islands, the level was still low. In Inverness, 42% of deaths were not certified by a doctor. In the cities, the Medical Officers of Health were chiefly responsible for the improvement in the numbers of medically certified deaths. Henry Littlejohn, the Medical Officer of Health for Edinburgh, threatened to use his powers to bring in the police to investigate every death that was not certified by a doctor, and this had an immediate impact. The Friendly Societies Act of 1882 also had an effect, for it obliged relatives to provide a medical certificate of the cause of death before claiming insurance money from any burial club that the deceased was enrolled in. The main problem in the Highlands was still in having access to a doctor at all, and this was not effectively solved until the introduction of the state-subsidized Highlands and Islands Medical Service in 1913.
The change in descriptions of causes of death can be seen on another page of the death register for Stornoway from 1890. All the deaths had been certified by the local doctors, and both the immediate and the underlying causes of death are given. Two of the young people died in a measles epidemic, which is noted, along with the 'proximate' or immediate causes of death, which were uraemia and pneumonia.