External causes on Medical Death Certificate in Spain 2009-2023: A Civil Registry or Judicial issue?

Introduction

Mortality data quality on external causes of death (EC) shows persistent limitations in validity and reliability. In Spain, two documental entries exit for the National Statistics: A) Judicial Administration (JA) for unknown/ criminally suspicious deaths (forensic autopsy); B) Civil Register via Medical Certificate of Death (CD) for all other deaths. The objective aimed to contrast EC reporting between CD and JA in Spain over 2009–2023.

Methods

An observational epidemiologic study of EC was conducted in 2 Spanish regions. ICD-10 EC blocks selected include Transport Accident, Other Accident, Suicide, Assault, Undetermined, Medical Complication, and Sequela. Notification included CD, and judicial paper form (pJA) or website (wJA). Time was split into 2009-2013, -2019, and –2023. Poisson regression with robust standard errors was applied to contrast age-adjusted death rates across notifications, registries, periods, age, and interactions.

Results

We studied 42,547 EC, 71% by JA. CD reported EC across all blocks and periods, except Assault and Undetermined in some registry periods. Suicide was CD-reported in all periods. Medical Complication and Sequela rates were higher in CD than JA. Other Accident were statistically higher in CD or similar to JA. One region reported no Sequela by JA. Most frequent EC in CD were drowning, submersion & suffocation (9%), accidental falls (8%), and complications of medical & surgical care (2%). In JA, most common EC were Suicide (39%), Traffic Accident (19%), and Accidental Fall (14%) across all ages. pJA rates were lower than wJA, except for Sequela. There were significant interactions on registry and notification types for Transport and Other Accidents, and Suicide. Unspecific causes accounted for 41% of total deaths and 17% of JA.

Conclusions

CDs enclose possible judicial causes. Notification types differed between registries for same EC blocks. The Civil Register should control for judicial causes of death.

Key messages

• Medical death certificates capture judicial causes —including suicide— that should be reported through judicial channels, revealing systematic overlap between both registries in Spain (2009–2023).

• High rates of unspecific external causes and divergent notification patterns across registries undermine data quality, urging coordinated reform between Civil and Judicial death reporting systems.