The death toll from Hurricane Florence has risen again, four months after the storm

The official death toll from Hurricane Florence in North Carolina rose to 43 last week, with the addition of a 55-year-old man from Carteret County who died of a heart attack in September while cleaning up after the storm.

The number of storm-related deaths stood at 41 at the beginning of November. It was increased to 42 later that month when authorities realized that a 76-year-old man who died when he lost control of his SUV on U.S. 58 in Jones County on Sept. 23 was on his way home following his evacuation from Emerald Isle.

The addition of these last two deaths highlights the government’s efforts to count everyone who died as a result of the storm. While official death tolls once included only people who were directly killed by a storm, by drowning, for example, or being hit by a falling tree, federal guidelines released in late 2017 encouraged governments to count indirect deaths as well.

And so the official death toll includes several people who died during evacuations and cleanup, even if the actual cause was a heart attack or a car accident well after the storm. Hurricane Florence made landfall near Wrightsville Beach on Sept. 14 and slowly moved inland over the next several days.

The Office of the Chief Medical Examiner in Raleigh, which makes the final decision, said last fall that if the time, place and circumstances of someone’s death were determined by the storm, then it gets counted. The state Department of Health and Human Services did not provide any details about the death added to the list last week, including the man’s name.

The medical examiner’s office has noted that indirect storm deaths can take longer to account for, especially where autopsies or investigations are needed to establish the cause or circumstances. It said there is no time limit for determining a final death toll from a natural disaster such as Florence.

Among the 43 storm-related deaths in North Carolina are two people who were apparently distraught over the impact of the storm and took their own lives. The second of those, a 69-year-old man in Robeson County whose home was damaged in the storm, died on Oct. 22, more than a month after the hurricane moved through North Carolina.