Purpose

In 1994, the Office of the Chief Coroner established the Obstetrical Care Review Committee. In 2004, the name of the committee was changed to the Maternal and Perinatal Death Review Committee.

The purpose of the MPDRC is to assist the Office of the Chief Coroner in the investigation, review and development of recommendations directed towards the prevention of future similar deaths relating to all maternal deaths regardless of cause. This includes all deaths during pregnancy and the post-natal period (which is considered to be up to 42 days after delivery). Any deaths after 42 days and up to 365 days post-delivery are reviewed if the cause of death is directly related to the pregnancy or a complication of the pregnancy.

The committee reviews stillbirths and neonatal deaths where the family, coroner or Regional Supervising Coroner have concerns about the care that the mother or child received.

Findings of legal responsibility or conclusions of law are not permitted under the Coroners Act.

Definition of maternal deaths, stillbirths, perinatal and neonatal deaths

The MPDRC reviews the deaths of all women who died “during pregnancy and following pregnancy in circumstances that could reasonably be attributed to pregnancy.” Deaths involving women who are pregnant, but where the death was not attributed to pregnancy are noted for statistical purposes and a condensed, executive review is conducted.

Maternal deaths are classified by the following criteria:

  • Antepartum – during pregnancy
  • Intrapartum - during delivery or immediately following delivery
  • Postpartum - < 42 days after delivery

This committee does not review late maternal deaths occurring > 42 days unless the cause of death is directly related to the pregnancy or a complication of the pregnancy.

Stillbirth is defined as the complete expulsion or extraction from the mother of a product of conception either after the 20th week of pregnancy or after the product of conception has attained the weight of 500 grams or more, and where after such expulsion or extraction there is no breathing, beating of the heart, pulsation of the umbilical cord or movement of voluntary muscle. (source: Vital Statistics Act of Ontario)

Perinatal deaths are defined as deaths during, at the time of, or shortly after birth, including home births.  

Neonatal deaths are defined as deaths within the first seven days after birth.

Aims and objectives

  1. To assist coroners in the Province of Ontario to investigate maternal and perinatal deaths and to make recommendations that may prevent similar deaths.
  2. To provide expert review of the care provided to women during pregnancy, labour and delivery, and the care provided to women and newborns in the immediate postpartum period.
  3. To provide expert review of the circumstances surrounding all maternal deaths in Ontario, in compliance with the recommendations of the Special Report on Maternal Mortality and Severe Morbidity in Canada (Special Report on Maternal Mortality and Severe Morbidity in Canada, Health Canada, 2004).
  4. To inform doctors, midwives, nurses, institutions providing care to pregnant and postpartum women and newborns, and relevant agencies and ministries of government about hazardous practices and products identified during case reviews.
  5. To produce an annual report that can be made available to doctors, nurses and midwives providing care to mothers and infants, and hospital departments of obstetrics, midwifery, radiology/ultrasound, anaesthesia and emergency for the purpose of preventing future deaths.
  6. To help identify the presence or absence of systemic issues, problems, gaps, or shortcomings of each case to facilitate appropriate recommendations for prevention.
  7. To help identify trends, risk factors, and patterns from the cases reviewed to make recommendations for effective intervention and prevention strategies.
  8. To conduct and promote research where appropriate.
  9. To stimulate educational activities through the recognition of systemic issues or problems and/or referral to appropriate agencies for action.
  10. Where appropriate, to assist in the development of protocols with a view to prevention.
  11. Where appropriate, to disseminate educational information. 

Note:  All of the above described objectives and attendant committee activities are subject to the limitations imposed by the Coroners Act of Ontario and the Freedom of Information and Protection of Privacy Act.

Structure and size

The committee membership consists of respected practitioners in the fields of specialty including: obstetrics, family practice, specialty neonatology, community pediatrics, pediatric and maternal pathology, anesthesiology, midwifery and obstetrical nursing.  The membership is balanced to reflect wide and practicable geographical representation as well as representation from all levels of institutions providing obstetrical care including teaching centers to the extent possible.  The chairperson will be a Deputy Chief Coroner or Regional Supervising Coroner or other person designated by the Chief Coroner.

Other individuals are invited to the committee meetings as necessary on a case by case basis (e.g. investigating coroner, Regional Supervising Coroner, other specialty practitioner relevant to the facts of the case, etc.).

Methodology

Investigating coroners and Regional Supervising Coroners refer cases to the committee for review. At least one member of the committee reviews the information submitted by the coroner and then presents the case to the other members. After discussion by the committee, a final case report is written consisting of a summary of events, discussion and recommendations (if any), intended to prevent future deaths. The report is then sent to the referring Regional Supervising Coroner who may conduct further investigation (if necessary). Recommendations are distributed to agencies and organizations that may be in a position to have them implemented or considered. Organizations are asked to respond back within six months with the status of implementation of recommendations.  

Where a case presents a potential or real conflict of interest for a committee member, the committee reviews the case in the absence of the member with the conflict.

When a case requires expertise from another discipline, an external expert reviews the case, attends the meeting and participates in the discussion and drafting of recommendations, if necessary.

Limitations

This committee is advisory to the coroner system and will make recommendations to the Chief Coroner through the chairperson.

The consensus report of the committee is limited by the data provided. Efforts are made to obtain all relevant data.

The MPDRC case reports are prepared for the Office of the Chief Coroner and are therefore governed by the provisions of the Coroners Act, the Vital Statistics Act, the Freedom of Information and Protection of Privacy Act and the Personal Health Information and Protection of Privacy Act.  Cases referenced in the annual report do not include identifying details.

It is important to acknowledge that these reports rely upon a review of the written records. The Coroner/Regional Supervising Coroner conducting the investigation may have received additional information that rendered one or more of the committee's conclusions invalid. Where a fact was made known to the chair of the committee prior to the production of the annual report, the case review was revised to reflect these findings.

Recommendations are made following a careful review of the circumstances of each death; they are not intended to be policy directives and should not be interpreted as such.

Responses received to recommendations are available to the public by contacting occ.inquires@ontario.ca.

This report of the activities and recommendations of the MPDRC is intended to provoke thought and stimulate discussion about obstetrical care and maternal and perinatal deaths in general in the province of Ontario.