All medical doctors in Hong Kong are familiar with the death certificate (Fig). Many of us have signed this form as a matter of course without thinking about how the death certificate came about, but it has an interesting early history.

Hong Kong became a British Colony in 1842. In the early 1830s, the British Parliament recognised the need for accurate records for the purposes of voting, planning, taxation, and defence. In 1837, legislation was passed to create a civil registration of births, marriages, and deaths in England and Wales and of British subjects living abroad.

In Hong Kong, although the total population, births and deaths had been reported every year since the colony was established, the information was inaccurate because of the lack of a census for birth and death registration. A census once every 10 years was carried out only after 1881. The border between China and Hong Kong was porous and people could travel readily between the two. During festivals or certain events such as the plague epidemic of 1894, half of the Chinese population of the colony disappeared to the Mainland. The Chinese had resisted registration of any kind for fear of taxation. Despite urging by the British Government, the colonial administration did not establish birth and death registration, partly because they did not wish to upset the Chinese and partly because it was costly to establish the infrastructure for such registration. The colonial administration also failed to provide official cemeteries for the Chinese until the 1870s.1

In 1872, unable to delay any longer, the Hong Kong Government enacted the Births and Deaths Registration Ordinance (No. 7 of 1872) that required all births to be registered within 7 days and all deaths within 5 days. The Registrar General acted as the Chief Registrar of Births and Deaths, assisted by district registrars who were police officers in different districts in Victoria and Kowloon. Burial could take place only after a valid death certificate had been obtained.2

An essential component of the death certificate was the cause of death, because it facilitated early identification of infectious disease epidemics. The 1872 Ordinance required an individual who was present at the death or in attendance during the illness or the occupier or a tenant of the house of the deceased to provide the particulars of the death. In some cases, the Registrar might request an enquiry by the Coroner and the death certificate would be issued only after the Registrar was satisfied with the cause of death as reported by the Coroner. Nonetheless there was no mention of a post-mortem examination. In addition, some individuals were buried without reporting to the Registrar; many Chinese would return to their native village to die when they developed a severe illness. For these reasons, and despite the 1872 Ordinance, stated cause of death was often inaccurate and the number of deaths among Chinese was underestimated.3

In 1888, the Magistrates (Coroners Powers) Ordinance was enacted wherein Coroners were abolished and their duties assumed by magistrates.4 The Ordinance empowered the Governor in Council to make rules for regulating the practice and procedures for post-mortem enquiries and examinations. When a dead body was brought to a hospital, the medical officer in charge of the hospital, government medical officer or deputised registered medical practitioner would carry out a preliminary external examination of the body and report in writing to the magistrate who might, if he deemed necessary, order an autopsy.

Autopsy had been performed prior to 1888 but very rarely among the Chinese in Hong Kong or in China because of the Chinese deep-seated aversion to autopsy and belief that it was a crime.5 Nevertheless in 1865, autopsies were carried out on prisoners who died following specific outbreaks in Victoria Gaol or from a fever of unknown origin.6 Autopsies were gradually accepted by the people in Hong Kong for pragmatic reasons. After the plague epidemic, public health practice required that the belongings of a person suspected to have died from the plague be ‘sanitised’ by burning to prevent the spread of infection. If death was confirmed not to be due to plague, the patient’s belongings and property could be kept and not burned. This provided an incentive for autopsy. The 1888 Ordinance required the cause of death to be determined when it was not known although there were still no proper facilities for post-mortem examination.

Another Births and Deaths Registration Ordinance was passed in 18967 when the general Register Office was transferred to the Sanitary Department with the duties of the Registrar of Births and Deaths now performed by the Head of the Sanitary Department. The district registers of births and deaths were still kept at police stations and the officers in charge of these stations and the principal clerk at every public dispensary were appointed as assistant registrars for the district. In 1897, the government appointed Dr Francis William Clark as the first Medical Officer of Health. His role included assisting the Registrar to ascertain cause of death.8

In 1907, the first two public mortuaries were established, one in Hong Kong and one in Kowloon, where post-mortem examinations could be carried out. Additionally, Governor Frederick Lugard appointed Dr Earnest Albert Shaw and Dr John Christopher Thomson as medical officers. They were required to perform an autopsy and determine cause of death for any individual who had died suddenly or by accident or violence, or under suspicious circumstances within the colony or had been brought into the colony.9

Although the 1896 Ordinance indicated that the principal clerk of the district public dispensary in addition to the district police officer could serve as assistant registrar for births and deaths, there was no public dispensary until later on. The first two public dispensaries financed by the government were established in Wan Chai and Tai Po in the late 1890s (probably in 1899). The one in Wan Chai was short-lived, closing in 1903. Nonetheless from 1906 until just before World War II, about 10 Chinese Public Dispensaries were established and financed by the Chinese elite, initially with the main purpose of reducing the number of ‘dumped bodies’ in the streets. During the plague of 1894, harsh laws required the home of the deceased to be thoroughly sanitised with whitewash, the furniture put into a large tank of disinfectant and contacts quarantined. As a result, patients were often left in the streets to die or dumped in the streets after their death. The Chinese Public Dispensaries were staffed by licentiates of the Hong Kong College of Medicine who were not allowed to practise in Hong Kong because their inadequate training (including lack of autopsy experience) barred them from registration under the Medical Registration Ordinance. Their main duty was to determine the cause of death of the dumped bodies but later, other duties were added including registration of births and deaths, treatment of patients and vaccinations.10 In 1908, they were authorised to sign death certificates for the first time.11

In 1887, Dr John Mitford Atkinson, who became the superintendent of the Government Civil Hospital, adopted the International Classification of Diseases that enabled the mortality of various diseases to be compared with other populations and the effects of intervention on the same population to be assessed.12 Thus, by 1908, death registration in Hong Kong was more effective and backed by proper ordinances and enforcement as well as autopsy facilities. Statistics became more useful because of standardisation of diagnoses of diseases but further improvement was still necessary.

1. Tam C. Death in Hong Kong: managing the dead in a colonial city from 1841 to 1913 [thesis]. Hong Kong: The University of Hong Kong; 2018.

2. Births and Deaths Registration Ordinance, No 7 of 1872, The Hong Kong Government Gazette, 27 July 1872.

3. The China Mail, 1879-04-30. 5 June 1879. Available from: https://mmis.hkpl.gov.hk/coverpage/-/coverpage/view?p_r_p_-1078056564_c=QF757YsWv5%2BzBV%2Fmy%2B7fMAilSsNss%2Bug&_coverpage_WAR_mmisportalportlet_o=0&_coverpage_WAR_mmisportalportlet_actual_q=%28%20all_dc.title%3A%28%22China%5C%20Mail%22%29%29%20AND+%28%20%28%20-all_dc.title%3A%28%E9%A6%99%E6%B8%AF%E8%8F%AF%E5%AD%97%29%29%29%20AND+%28%20verbatim_dc.collection%3A%28%22Old%5C%20HK%5C%20Newspapers%22%29%29&_coverpage_WAR_mmisportalportlet_sort_order=desc&_coverpage_WAR_mmisportalportlet_sort_field=dc.publicationdate_bsort&_coverpage_WAR_mmisportalportlet_log=Y&_coverpage_WAR_mmisportalportlet_freetext_filter=1879-04-30&_coverpage_WAR_mmisportalportlet_filter=dc.publicationdate_dt%3A%5B*+TO+1900-01-01T00%3A00%3A00Z%5D. Accessed 27 Sep 2021.

4. Magistrates (Coroners Powers) Ordinance, 1888, Historical Laws of Hong Kong. Available from: https://oelawhk.lib.hku.hk/items/show/1661. Accessed 27 Sep 2021.

5. Beh PS, Wu HY. The porcelain autopsy table and early post-mortem examinations in Hong Kong. Hong Kong Med J 2018;24:434-5.

6. Colonial Surgeon’s Report with Returns on the Sanitary Conditions of the Colony for the Year 1865. The Hong Kong Government Gazette, 17 March 1866.

7. Births and Deaths Registration Ordinance, No. 7 of 1896, The Hong Kong Government Gazette, 11 August 1896.

8. Government Notification No 299, The Hong Kong Government Gazette, 24 July 1897.

9. Appointments no 663, The Hong Kong Government Gazette, 22 October 1907.

10. Chan-Yeung M. A Medical History of Hong Kong: The Development and Contributions of Outpatient Services. Hong Kong: The Chinese University of Hong Kong Press; 2021: 14-6. Crossref

11. Chinese Medical Practitioners trained in Western Medical Sciences authorized to grant death certificates. The Hong Kong Government Gazette, 10 July 1908.

12. Chan-Yeung M. A Medical History of Hong Kong 1842-1941. Hong Kong: The Chinese University of Hong Kong Press; 2018: 246. Crossref