Denuncias por responsabilidad profesional médica en Barcelona (2004-2009). Análisis médico-forense / Medical professional liability claims in Barcelona (2004-2009). Medico-legal analysis

En los últimos años ha habido un incremento de reclamaciones contra médicos por presunta mala praxis. Nuestro objetivo ha sido analizar retrospectivamente las denuncias por responsabilidad médica en los juzgados de Barcelona durante los años 2004-2009, evaluadas en el Instituto de Medicina Legal y Ciencias Forenses de Cataluña. MATERIAL Y MÉTODO: Se realizó a partir de 3 bases de datos: la primera, las 283 periciales elaboradas por los médicos forenses durante estos años; la segunda, el programa informático judicial TEMIS-2; y la tercera, revisión de sentencias judiciales. RESULTADOS: En 257 casos (90,81%) la reclamación fue penal, 18 (6,36%) procedimientos contencioso-administrativos, 5 civiles (1,77%) y 3 de Fiscalía (1,06%). La edad media fue de 48,38 años (DE±19,39), en el 62,77% la perjudicada fue una mujer, siendo estas las que sufrieron más secuelas. En el 88,34% la reclamación era contra un médico, siendo la más habitual el mal resultado terapéutico (32,86%). Las especialidades más denunciadas fueron la traumatología, obstetricia y ginecología y cirugía general. Hubo más reclamaciones en la sanidad privada. En el 72,41% de los casos que llegaron a juicio la sentencia fue absolutoria y de los 8 que fueron condenados, solo en uno hubo prisión. La mediana del tiempo hasta la sentencia fue de 1.602 días. CONCLUSIONES: La vía penal es la más frecuente. Las mujeres reclaman más y sufren más secuelas. Las especialidades quirúrgicas son las más denunciadas. En el 27,59% de los casos que llegaron a juicio hubo sentencias condenatorias y solo en uno privación de libertad

In recent years there has been an increase in claims against doctors for alleged malpractice. Our objective was to retrospectively analyze complaints of medical liability in the courts of Barcelona between 2004-2009, evaluated at the Institute of Legal Medicine and Forensic Sciences of Catalonia. MATERIAL AND METHOD: We used 3 databases: the first, the 283 forensic reports prepared by forensic doctors during those years; the second, the judicial computer programme TEMIS-2; and the third, a review of judicial sentences. RESULTS: In 257 cases (90.81%) the claim was criminal, 18 (6.36%) contentious-administrative proceedings, 5 civil (1.77%) and 3 Prosecutor's Office claims (1.06%). The average age was 48.38 years (SD±19.39), in 62.77% the injured party was a woman, and they suffered more sequelae. In 88.34% the claim was against a doctor, a poor therapeutic outcome being the most common (32.86%). The most reported specialties were traumatology, obstetrics and gynaecology, and general surgery. There were more complaints in private healthcare. In 72.41% of the cases that came to trial the sentence was acquittal, and of the 8 convictions, only one was imprisoned. The median time to sentencing was 1,602 days. CONCLUSIONS: The criminal route is the most frequent. Women claim more and suffer more consequences. Surgical specialties are the most reported. In 27.59% of the cases that came to trial there were convictions, and only one resulted in deprivation of liberty

Socioeconomic inequalities in suicide mortality in Barcelona during the economic crisis (2006-2016): a time trend study.

OBJECTIVES: This study aimed to analyse trends in socioeconomic inequalities in suicide mortality in Barcelona before and after the start of the economic crisis that started at the end of 2008, including both individual factors and contextual factors of the deceased's neighbourhood of residence. DESIGN: This is a trend study of three time periods: pre-economic crisis (2006-2008), early crisis (2009-2012) and late crisis (2013-2016). SETTING: Total Barcelona residents between 2006 and 2016 (≥25 years of age) and death data derived from the Judicial Mortality Registry of Barcelona. PARTICIPANTS: 996 deaths by suicide between 2006 and 2016 were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcomes were age-standardised suicide mortality rates and the associations (relative and absolute risk) between suicide mortality and individual and contextual characteristics for the three time periods. RESULTS: From 2006 to 2008, men with a lower educational level were more likely to commit suicide than better educated men (relative risk (RR)=1.46; 95% CI 1.11 to 1.91). This difference disappeared after the onset of the crisis. We found no differences among women. From 2013 to 2016, suicide risk increased among men living in neighbourhoods with higher unemployment levels (RR=1.57; 95% CI 1.09 to 2.25) and among women living in neighbourhoods with a higher proportion of elderly people living alone (RR=2.13; 95% CI 1.15 to 3.93). CONCLUSIONS: We observed risks for suicide among men living in neighbourhoods of Barcelona with higher unemployment levels and among women living in neighbourhoods with a higher proportion of elderly people living alone. Inequalities in suicide mortality according to educational level tended to disappear during the crisis among men. Thus, it is important to continue to monitor suicide determinants especially in times of economic crisis.

Las muertes con intervención judicial y medicolegal y su impacto en la estadística de causas de muerte en Cataluña / Deaths with medicolegal intervention and its impact on the cause-of-death statistics in Catalonia, Spain

Introducción. Los boletines estadísticos correspondientes a las defunciones que requieren intervención judicial (DIJ) y actuación forense contienen un número elevado de causas de muerte mal definidas. El objetivo es presentar los resultados de la recuperación de datos a partir de las autopsias judiciales del año 2013 en Cataluña y analizar el impacto de esta información sobre la estadística de causas de muerte. Material y métodos. Se seleccionaron del Registro de Mortalidad de Cataluña las defunciones con intervención judicial que tenían como causa de muerte unas determinadas afecciones mal definidas, según criterios de codificación de la OMS. Se recuperó la información de los registros de autopsia de los centros de Patología Forense del Instituto de Medicina Legal y Ciencias Forenses de Cataluña (IMLCFC). Resultados. Las DIJ representan el 6% de la mortalidad total de Cataluña, el 42,9% de las causas externas y el 77% de las mal definidas. De los 3.639 casos de DIJ del año 2013 se revisó un 43,4% (n=1.578) y se obtuvo información que mejoró la causa de muerte del 78,4% de los revisados. La información recuperada aumentó un 61,3% las intoxicaciones accidentales, un 32,6% los suicidios, un 28,9% los homicidios, un 27,4% las caídas, un 22,7% los accidentes de tráfico y un 5,2% la cardiopatía isquémica, con el equivalente aumento de las tasas de mortalidad por estas causas. Conclusiones. La información de las autopsias judiciales tiene un gran impacto en las estadísticas de causa de muerte, especialmente en las causas externas y la cardiopatía isquémica. Un informe forense sobre la causa y las circunstancias de la muerte, de manera que permita fácilmente su codificación posterior, así como la transmisión directa de estos datos a la oficina estadística serían la mejor solución para evitar la pérdida de información que se produce actualmente (AU)

Introduction. The statistical forms corresponding to deaths that require judicial and forensic interventions contain a very high number of ill-defined causes of death. The objective is to show the results of data recovery from the forensic autopsies and to analyse the impact of this information on the cause-of-death statistics for the year 2013 in Catalonia (Spain). Material and methods. Deaths with judicial intervention with an ill-defined cause of death according to the WHO coding standards were selected from the Catalan Mortality Registry. Information was recovered from the autopsy registers of the Forensic Pathology centres of the Institute of Legal Medicine and Forensic Science of Catalonia (IMLCFC). Results. Deaths with judicial intervention represent 6% of total mortality in Catalonia, 42.9% due to external causes and 77% pertaining to ill-defined causes-of-death. There were 3,639 cases of death with judicial intervention, of which 43.4% (n=1,578) were reviewed, resulting in information that improved the cause of death in 78.4% of cases. The information retrieved increased accidental poisoning by 61.3%, suicides by 32.6%, homicides by 28.9%, falls by 27.4%, traffic accidents by 22.7% and ischaemic heart disease by 5.2%, with the equivalent increase in the mortality rates from these causes. Conclusions. The forensic autopsy information has a significant impact on cause-of-death statistics, especially external causes and ischemic heart disease. A forensic report concerning the cause and circumstances of death, structured to facilitate further coding and the direct transmission of data to the statistical office, would be the best solution to prevent the loss of information currently experienced (AU)

New insights in the analysis of blunt force trauma in human bones. Preliminary results.

Determining the time of injury is an important but still a challenging task in forensic anthropology. In literature, many descriptions can be found to make a distinction between perimortem and postmortem fractures. Characteristics that are more related to fractures in fresh conditions, however, are not extensively investigated. This study compared 28 perimortem fractures from autopsies and 21 both fresh and dry experimentally reproduced human bone fractures. Preliminary results showed the following five distinct traits that might be related to perimortem conditions: layered breakage, bone scales, crushed margins, wave lines and flakes with matching flake defect. These distinct traits might not only be good estimators of perimortem trauma but also may be an indicator of trauma in intra vitam conditions, especially related with muscular reaction to injury. Furthermore, layered breakage seems to be a good trait to infer the biomechanics of trauma.

Prevalencia de marcadores de los virus de la inmunodeficiencia humana y la hepatitis C en los cadáveres judiciales de Barcelona y Lleida / Prevalence of human inmunodeficiency virus and hepatitis C virus markers in forensic autopsy cases in Barcelona and Lleida

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Managing the identification of the mortal victims run over by a train in the Castelldefels railway accident (Barcelona).

The identification of disaster victims is the formal, organized process of identifying multiple bodies after an incident with multiple victims. The appropriate management of these incidents, particularly of the bodies, is one of the most crucial aspects of disaster response and its importance has led to the evolution of the concept of Disaster Victim Management. The aim of this study is to report how the process of identifying the 12 mortal victims of a railway accident in June 2010 in Castelldefels (Barcelona) was managed. The methodology used complied with the National Protocol for medical forensic and scientific police response to mass casualty incidents. The family assistance center also served as an ante mortem (AM) office. Despite the fragmentation of the bodies, all the victims were identified satisfactorily. The main problems observed during the management of the disaster were due to the state of the bodies, which raised many doubts as to the number of fatalities. The experience prompted a proposal to establish some recommendations on limiting the number of fragments to be analyzed genetically. We would like to stress the importance of setting up a Data Integration Center which brought together all the participating institutions, and collected and supervised all the different identification reports in a single comprehensive text addressed to the competent legal authority.

Estudio prospectivo de la sumisión química con finalidad sexual en Barcelona / A prospective study of drug-facilitated sexual assault in Barcelona

Fundamento y objetivo: Determinar la frecuencia y las características de la sospecha de sumisión química (SSQ) entre las víctimas de agresión sexual en Barcelona. Material y métodos: Estudio prospectivo de personas adultas atendidas en un servicio de urgencias por posible agresión sexual y con valoración médico-forense en la ciudad de Barcelona durante 2011. Resultados: Se incluyeron 114 casos, de los cuales 35 (30,7%) cumplieron los criterios de SSQ. Este grupo se diferenció del resto en mayor frecuencia de: amnesia, hechos nocturnos y posteriores a actividad social y a consumo de alcohol, agresor recién conocido y origen extranjero. En este grupo se detectó etanol en sangre u orina en el 48,4% de los casos analizados; la etanolemia media estimada en el momento de los hechos fue de 2,29 g/l (DE 0,685). Asimismo, se detectaron otras sustancias psicoactivas en el 60,6%, mayoritariamente drogas de abuso estimulantes. Conclusiones: La SSQ es frecuente entre las personas atendidas por agresión sexual en Barcelona. La principal sustancia depresora identificada en estos casos es el etanol, que contribuye a la vulnerabilidad de las víctimas (AU)

Background and objective: To determine the frequency and characteristics of suspected drug-facilitated sexual assault (DFSA) among the victims of sexual assault in Barcelona. Material and methods: Prospective study of every adult consulting an emergency service because of alleged sexual assault and receiving forensic assessment in the city of Barcelona in 2011. Results: A total of 35 of 114 cases (30.7%) met suspected DFSA criteria. Compared with the other victims, suspected DFSA cases were more likely to experience amnesia, to have been assaulted by night, after a social situation and by a recently acquainted man, to have used alcohol before the assault and to be foreigners. In this group ethanol was detected in blood or urine in 48.4% of analyzed cases; their mean back calculated blood alcohol concentration was 2.29 g/l (SD 0.685). Also, at least one central nervous system drug other than ethanol was detected in 60,6%, mainly stimulant drugs of abuse. Conclusions: Suspected DFSA is frequent among victims of alleged sexual assault in Barcelona nowadays. The depressor substance most commonly encountered is alcohol, which contributes to victims’ vulnerability (AU)

[A prospective study of drug-facilitated sexual assault in Barcelona]. / Estudio prospectivo de la sumisión química con finalidad sexual en Barcelona.

BACKGROUND AND OBJECTIVE: To determine the frequency and characteristics of suspected drug-facilitated sexual assault (DFSA) among the victims of sexual assault in Barcelona. MATERIAL AND METHODS: Prospective study of every adult consulting an emergency service because of alleged sexual assault and receiving forensic assessment in the city of Barcelona in 2011. RESULTS: A total of 35 of 114 cases (30.7%) met suspected DFSA criteria. Compared with the other victims, suspected DFSA cases were more likely to experience amnesia, to have been assaulted by night, after a social situation and by a recently acquainted man, to have used alcohol before the assault and to be foreigners. In this group ethanol was detected in blood or urine in 48.4% of analyzed cases; their mean back calculated blood alcohol concentration was 2.29g/l (SD 0.685). Also, at least one central nervous system drug other than ethanol was detected in 60,6%, mainly stimulant drugs of abuse. CONCLUSIONS: Suspected DFSA is frequent among victims of alleged sexual assault in Barcelona nowadays. The depressor substance most commonly encountered is alcohol, which contributes to victims' vulnerability.

[Medical-legal conduct with individuals in judicial or police custody]. / Actuación medicolegal en personas en custodia judicial o policial.

The problems involved in caring for individuals in custody, as well as deaths that occur during custody, are relevant aspects of legal and forensic medicine in terms of the possible criminal, civil and administrative responsibility of health professionals and/or public or private institutions that might hold individuals in custody and deprived of freedom. The rule of law should ensure that these cases comply with state law and international agreements and treaties related to human rights and the special treatment of individuals deprived of freedom in hospitals or detention centers. Of particular mention is the medical-forensic activity regarding deaths associated with the use of control holds and/or restraint during the detention of individuals by members of the armed forces or law enforcement or in healthcare centers by safety and healthcare personnel. In these cases, both the immediate healthcare treatment subsequent to the events and the medical-forensic study should be particularly careful. These situations, which are often high profile, cause social alarm and involve judicial actions that can result in especially severe liabilities.

Autopsias judiciales en personas mayores de 65 años / Forensic autopsies of elderly patients

Introducción. Las personas mayores de 65 años son pacientes con pluripatología, siendo la causa de muerte la confluencia de múltiples factores. El objetivo del presente estudio es conocer el perfil y las causas de muerte en una serie de autopsias judiciales de personas de la tercera edad en Barcelona. Material y métodos. Estudio descriptivo y retrospectivo de las autopsias judiciales en mayores de 65 años realizadas en el Servicio de Patología Forense de Barcelona del Instituto de Medicina Legal de Cataluña entre octubre de 2010 y septiembre de 2011. Resultados. Se practicaron 1.494 autopsias, de las cuales 641 (42,9%) correspondieron a fallecidos de una edad de 65 o más años (63,8% varones y 36,2% mujeres). De estas 179 (28%) fueron muertes violentas (57% accidentales, 31,3% suicidas, 8,4% indeterminadas y 3,4% homicidios). Se solicitó análisis toxicológico en 277 casos y las sustancias más frecuentemente halladas fueron etanol en 34 casos (12,8%) y antidepresivos en 30 (11,3%). Conclusiones. La información procedente de las autopsias judiciales en personas mayores de 65 años aporta más información clínica que judicial (AU)

Introduction. Comorbidity is common in people over 65 years, where the confluence of multiple factors can be the cause of death. The aim of this study is to know the profile and the causes of death in a series of judicial autopsies of elderly persons in Barcelona. Material and methods. Descriptive and retrospective study of the judicial autopsies of persons aged 65 years or more that were performed at the Forensic Pathology Service of Barcelona of the Institute of Legal Medicine of Catalonia between October 2010 and September 2011. Results. Among 1494 autopsies performed, 641 (42.9%) were from people aged 65 years or more (63.8% men and 36.2% women). Among them, 179 (28%) were violent deaths (57% accidents, 31.3% suicides, 8.4% undetermined and 3.4% homicides). A toxicological analysis was performed in 277 cases and the substances more commonly found were ethanol in 34 cases (12.8%) and antidepressants in 30 (11.3%). Conclusions. The information provided by the forensic autopsies of persons aged 65 years or more is more clinical than judicial (AU)

Actuación medicolegal en personas en custodia judicial o policial / Medical-legal conduct with individuals in judicial or police custody

La problemática asistencial de personas en custodia así como la muerte en custodia son aspectos relevantes para la medicina legal y forense, en relación con la posibilidad de responsabilidad penal, civil y administrativa de los profesionales sanitarios y/o instituciones públicas o privadas que puedan tener en custodia sujetos privados de libertad. Un estado de derecho debe garantizar que en estos casos se cumplan la legislación estatal y los tratados y compromisos internacionales relacionados con los derechos humanos, y el tratamiento especial de personas privadas de libertad en centros hospitalarios o de detención. Mención particular merece la actuación médico forense en las muertes en situaciones de reducción y/o contención en el momento de la detención de un sujeto por miembros de las fuerzas y cuerpos de seguridad, o en centros asistenciales por personal de seguridad o asistencial. En estos casos, tanto el tratamiento asistencial inmediato posterior a los hechos como el estudio médico forense deberán ser particularmente cuidadosos. Estas situaciones, habitualmente mediáticas, provocan alarma social y conllevan actuaciones judiciales que puede derivar en responsabilidades especialmente graves (AU)

The problems involved in caring for individuals in custody, as well as deaths that occur during custody, are relevant aspects of legal and forensic medicine in terms of the possible criminal, civil and administrative responsibility of health professionals and/or public or private institutions that might hold individuals in custody and deprived of freedom. The rule of law should ensure that these cases comply with state law and international agreements and treaties related to human rights and the special treatment of individuals deprived of freedom in hospitals or detention centers. Of particular mention is the medical-forensic activity regarding deaths associated with the use of control holds and/or restraint during the detention of individuals by members of the armed forces or law enforcement or in healthcare centers by safety and healthcare personnel. In these cases, both the immediate healthcare treatment subsequent to the events and the medical-forensic study should be particularly careful. These situations, which are often high profile, cause social alarm and involve judicial actions that can result in especially severe liabilities (AU)

Criterios medicolegales en la valoración de la responsabilidad profesional médica / Medicolegal criteria in the assessment of medical professional liability

Las denuncias contra médicos por presunta mala praxis son relativamente frecuentes en nuestro medio judicial, su abordaje jurídico y medicolegal es complejo, y los informes periciales solicitados constituyen un reto para la medicina legal y forense. En este trabajo se revisan los principales estudios realizados sobre los denominados efectos adversos en el medio hospitalario, se diferencian de los errores y de las imprudencias, y se comenta que las edades extremas de la vida, la asistencia compleja o urgente y la estancia hospitalaria prolongada son algunas de las circunstancias que favorecen su presentación. Se explica la intervención del médico forense en estos casos y se describen los elementos necesarios para la valoración pericial. Finalmente, se ofrecen unos consejos prácticos para la elaboración del informe pericial, haciendo énfasis en la crucial importancia de tener una sólida formación medicolegal para realizar dichos informes, además de tener amplios conocimientos en la materia médica a peritar (AU)

Professional liability claims against physicians for supposed medical malpractice are relatively common in our country, their legal and medicolegal approach is complex and the expert reports requested constitute a challenge for forensic medicine. In this paper we review the main studies carried out about hospitalized patients adverse events, we distinguish between adverse events, errors and negligence and we comment that extremes of age, complex care, urgent care and a prolonged hospital stay are associated with them. We explain what the forensic physician role in these cases is and we describe the necessary requirements for the expert report. Finally we give practical advice for doing the medicolegal report. The expert or consultant in a judicial setting needs a sound medicolegal training to do these reports, besides to have an extensive knowledge in the specific medical specialty concerned (AU)

Aspectos medicolegales de la muerte súbita cardiaca / Medicolegal considerations in sudden cardiac death

La muerte súbita, de origen cardiaco u otro, se ha considerado en el ámbito medicolegal el ejemplo característico de muerte sospechosa de criminalidad. Su presentación rápida y su carácter inesperado, con desconocimiento de la causa última de muerte, no permiten descartar su origen violento. Esto obliga al médico asistencial a la emisión del correspondiente parte judicial de defunción, habitualmente sustituido por llamada telefónica al juzgado o canalizada a través de las fuerzas de seguridad. A medida que conocemos mejor la casuística, se facilita el diagnóstico de síndromes de predominio familiar y/o base genética que precisarán de los profesionales del campo de la cardiología consejo genético y estudios familiares. Los ejemplos más característicos son las enfermedades arritmogénicas familiares o algunas miocardiopatías. Estas entidades están constituyendo un serio reto para su caracterización, y se habla ya en términos de autopsia molecular, en un intento de la patología forense de responder a las necesidades sociales en el campo de la salud pública (AU)

Sudden death, whether of cardiac origin or not, is regarded as the typical example of a suspicious criminal death in forensic medicine. Its sudden and unexpected character, without the knowledge of the final cause of death, makes it not possible to discard violence as one possible cause of death. Consequently, health care doctors must make an accurate legal report of the death, with or without telephone call to the first-instance criminal court or addressed to the police. As far as we know better all the cases, we provide diagnoses of family and/or genetic-based syndromes which will require genetic advice and family studies to be performed by cardiologists. The most typical examples are family arrhythmogenic disorders or some cardiomyopathies. These conditions are a serious challenge for their characterization, in terms of molecular autopsy, in an attempt of forensic pathology to answer the social needs in the field of Health care (AU)

Entrenamiento en la identificación de víctimas múltiples en el Instituto de Medicina Legal de Catalunya: lecciones aprendidas / Identifying tracking disaster victims in Instituto de Medicina Legal de Catalunya: learned lessons

Los principales problemas fueron la numeración en el levantamiento de cadáver-zona de registro, la coordinación médico forense-policial y en la zona del control de calidad. A pesar del buen resultado se evidenció la necesidad de formación especializada; realizar simulacros parecidos multidisciplinares y de adecuación de la normativa a las instalaciones propias. Ante un suceso con víctimas múltiples debemos adaptarnos a la legislación vigente (Real Decreto 32/2009: protocolo nacional de actuación médico-forense y de Policía Científica en sucesos con víctimas múltiples). El objetivo principal de nuestro estudio fue valorar la respuesta médico-forense mediante un simulacro con atentado bomba, con 11 individuos fallecidos siguiendo la mencionada legislación. En el levantamiento había 8 cuerpos y 22 restos. La duración programada fue de 5h. En este tiempo estaban muy avanzadas las identificaciones de 8 personas (5 mediante estudio necrodactilar, odontología y ADN y 3 mediante estudio necrodactilar y ADN)(AU)

When a disaster involving multiple victims occurs we must comply with the legal norms in force in Spain (Royal Decree 32/2009, enacting the National Protocol for the Intervention of Forensic Doctors and Scientific Police in Mass Disaster). The main aim of our study was to assess the response of Forensic Doctors through a practice simulating a bomb attack with 11 mortal victims. At the disaster scene there were 8 bodies and 22 corpse remains to be identified. The expected duration was 5 hours. In that time the identification of 8 persons was well under way (5 using fingerprint identification, odontology and DNA, and 3 using fingerprint identification and DNA). The numbering of the bodies at the specific area of the disaster scene, the coordination of Forensic Doctors and Scientific Police and the management of the quality control area were the main problems. Despite of the good results achieved, the need for specialised training of the professionals participating in this type of intervention, the need to conduct similar multidisciplinary exercises, and the adaptation of the protocol to the specific guidelines of the Catalan Institute of Legal Medicine was evident(AU)

Síndrome de muerte súbita de varones jóvenes tras detención policial. Otros factores de riesgo / Sudden death syndrome in young males after police detention. Other risk factors

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Aspectos médico-legales de la responsabilidad profesional médica / Medicolegal aspects of medical resposibility

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