Introduction

The OCC investigates paediatric deaths that occur within Ontario each year. The investigation and review of paediatric deaths is an area that continues to be one of the most important and challenging areas within the OCC mandate. The deaths of children and youth are challenging both from a psychosocial and investigative perspective.

The Paediatric Death Review Committee - Medical (PDRC) is a multi-disciplinary committee that consists of specialized practitioners in paediatric pathology, paediatric critical care, community paediatrics, and paediatric emergency medicine. When indicated, the Committee is assisted by additional paediatric subspecialists. The membership is balanced to reflect Ontario’s geography and includes differing levels of institutions that provide paediatric care and teaching centres, when possible.

The PDRC strives to develop a comprehensive understanding of how deaths of children occur and how they could be prevented. The Committee analyzes and considers the medical issues involved in the time preceding a child or youth’s death to gain a better understanding of the circumstances of the death. The Committee, where appropriate, makes both case-specific and systemic recommendations that could assist with the prevention of further deaths.

This annual report is intended to provoke thought and stimulate discussion about paediatric deaths in Ontario and contains statistical information about cases reviewed and the resulting recommendations.

Review process

Case referrals for PDRC evaluation include:

  1. The death of a child or youth in which there are questions about the clinical diagnosis, cause and/or manner of death, or

  2. The medically complex death of a child or youth when there are concerns regarding their interactions with the healthcare system, including systemic issues that may have affected their care.

Case assignment occurs by aligning the practice profile and expertise of the committee members with the circumstances of each case. For example, paediatric deaths from a community setting will be reviewed by one of the community paediatricians. The review process involves analyzing the existing record of the young person. The record routinely includes medical records, the Coroner’s Investigation Statement, the Report of the Post-Mortem Examination, toxicology report, police report and other relevant documents.

At committee meetings, the primary reviewer presents the findings to the members for discussion. This provides an opportunity for discussion about issues that may have been identified through the review. The Committee may develop recommendations based on the findings of the review. The primary reviewer will compose a final report reflecting the Committee’s consensus opinion. The report, which will include the cause and manner of death and any Committee recommendations, is provided to the referring Regional Supervising Coroner by the Chair. If the recommendations are systemic, the responsive ministry, organization, agency, or individuals are also notified by the Chair.

Where a death review presents a potential or real conflict of interest for a committee member, that member does not participate in the review process.

Limitations

The PDRC death reports are prepared for the OCC and are governed by 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.

The consensus report of the Committee is limited by the information provided. While efforts are made to obtain all relevant data, it is important to acknowledge that these reports are generated from a review of the written records. Sometimes, the Coroner/Regional Supervising Coroner conducting the investigation may receive additional information not included in the records. Such information may, in certain cases, affect one or more of the Committee's conclusions and/or recommendations.

It is pertinent to note that recommendations are made following a careful review of the circumstances of each death; they are not intended to be policy directives.

Recommendations

One of the primary goals of the PDRC is to make recommendations aimed at preventing further deaths. Recommendations are distributed to relevant organizations and agencies through the Chair.

Organizations and agencies are asked to respond to the Executive Lead on the status of implementation of issued recommendations within six months of receiving them.   In the current legislative framework for death investigations, PDRC recommendations are not legally binding and there is no legal obligation for agencies and organizations to implement however, the responses received reflect the seriousness taken in consideration of recommendations.

Responses to recommendations are part of the public record and are available by contacting occ.inquiries@ontario.ca.