Appendix: Summary of 2022 cases and recommendations
| PDRC file number | Number of recommendations | Case summary | Recommendation(s) | Theme of recommendations |
|---|---|---|---|---|
| 2022-01 | 1 | This case involved an infant with a past medical history of asthma who died of respiratory failure due to lower respiratory tract infection. A contributing factor was a misplaced endotracheal tube leading to hypoxia and resultant cardio-respiratory arrest. |
| Quality of care Policy and procedure Transport |
| 2022-02 | 3 | This case involved an infant with a long/significant medical history who died due to cardiorespiratory complications of repaired Congenital Heart Disease. |
| Policy and procedure |
| 2022-03 | 1 | This case involved a child with a medical history of mild, intermittent asthma. This child died as a result of lymphocytic myocarditis. |
| Quality of care |
| 2022-04 | 0 | This case involved a toddler with no significant past medical history. This toddler died of bacterial meningitis caused by Hemophilus influenzae type A. | Not applicable | Not applicable |
| 2022-05 | 1 | This case involved a child who died of shock due to ischemic bowel due to strangulation by mesenteric fibrous band. |
| Policy and procedure |
| 2022-06 | 3 | This case involved a newborn whose death was caused by bilateral pneumothorax due to tracheal perforation due to endotracheal intubation as a consequence of gastric perforation with peritonitis and prematurity causing growth restriction. |
| Quality of care Policy and procedure Education/ training Other |
Updated: October 15, 2025
Published: February 25, 2025