According to RSMo 193.145.7, if the circumstances suggest that a death was caused by other than natural causes, the medical examiner or coroner shall determine the cause of death.
Primary or attending physicians can certify death certificates only on natural, non-Medical Examiner, cases.
If an injury either caused or contributed to the death, the death shall be reported to the Medical Examiner’s Office (MEO) at 816-881-6600 for determination and certification of the cause and manner of death. This applies even if the injury was a significant amount of time prior to the death. For example, if a traffic accident left one paralyzed and that individual years later died from sepsis due to a decubitus ulcer, the trauma during the accident which caused the paralysis is an underlying cause of death; this death would then be required to be reported to the MEO.