Message from the chair

As Chair of the Paediatric Death Review Committee (PDRC) at the Office of the Chief Coroner (OCC), I am honored to present the 2022 annual report. This report reflects our collective commitment to better understanding the circumstances surrounding the deaths of children in Ontario and contributing to efforts that can prevent further tragedies.

The investigation and review of child deaths is an area that continues to be one of the most important and challenging parts of the OCC mandate. The PDRC provides a framework to capture systemic healthcare issues, regarding an individual’s interactions with the healthcare system and offers recommendations. In 2022, the PDRC reviewed cases involving six deaths and generated nine recommendations.

This year’s annual report follows a different format from previous years, focusing on the reviews conducted by the PDRC-Medical and highlighting the resulting recommendations. Going forward, the report will no longer be combined with the Child and Youth Death Review and Analysis (CYDRA) Unit; however, the PDRC continues to work closely with the CYDRA Unit to help learn from child deaths to prevent further ones.

Reviews and recommendations prepared by the PDRC are widely distributed to healthcare organizations, regulatory bodies and other relevant agencies and organizations throughout the province. Since its inception, the PDRC has continued the valuable work of identifying important recommendations that can make a significant contribution to community safety and are instrumental in bringing preventative strategies to the attention of organizations.

I would like to express my gratitude for the hard work, dedication, and commitment of the committee members and their ongoing commitment to child death review. Their work is well documented in this annual report.

I look forward to the continued work with others toward the shared goal of improving the health, safety and well-being of Ontario's children and youth.

Dr. Joel Kirsh., MD, MHCM, LLM, FRCPC
Regional Supervising Coroner – Central East Region
Chair, Paediatric Death Review Committee