One of the important benefits of PDRC – medical review is informing medical systems through recommendations using a “no blame” approach. The focus is on preventing further deaths via:

  • Systemic changes;
  • Changes in professional practice; and
  • Response to emerging trends.

Given the PDRC – medical referral criteria, recommendations are commonly directed to health care facilities. The collective expertise of the committee provides comprehensive reports that can be helpful to inform a healthcare organization’s Quality of Care Review processes. The findings and recommendations in the reports create an opportunity for the organization to see the potential for improvement in its internal processes or policies to avoid similar outcomes in the future.

In 2018, the four reviews resulted in eight recommendations. There was one case that resulted in no recommendations.

Summary of 2018 recommendations made by PDRC – medical

The recommendations made from the PDRC – medical reviews in 2018 focused on the following themes and were addressed to the identified organizations:

Summary of 2018 recommendations
Organization(s) asked to respond to recommendationTheme of recommendation(s)Number of reviews where theme was identified 2018
Health care organizationsQuality of Care3
Treating health care professionalsQuality of Care1
Health care organizations / 
Treating health care professionals
Differential diagnosis3
Health care organizationsCommunication2
Health care organizationsDocumentation2
Health care organizationsTransport1
Health care organizationsEducation3

Some cases resulted in multiple recommendations touching on different themes.

Themes arising during medical reviews

Themes are often identified in individual case reviews and sometimes patterns may emerge when similar issues are observed in other reviews. Over time, the PDRC – medical has identified and compiled a number of themes that have been common in child death reviews. The benefit of having a thematic approach is that the recurring themes can become an agent for systemic change. Over the past several years, there have been a number of initiatives stemming from PDRC – medical recommendations that have enhanced paediatric health care in Ontario. 

Themes from 2018

The cases reviewed by the PDRC – Medical in 2018 were associated with four key themes. Some cases had more than one theme identified.

While these themes are consistent with past findings, by taking the extra step of evaluating for emerging trends, a refined focus for recommendations is taken with a view of systemic improvement instead of only considering the individual cases. The consistent themes, and issues associated with each, are:

Treatment - Quality of Care

The following treatment and/or quality of care issues were identified:

  • Management of temperature, respiratory symptoms and increased white cell count in the post-operative period in a potentially medically fragile child;
  • The criteria for activation of the Critical Care Response Team;
  • Hospital policies and procedures related to the dosing, route and rate of administration for medications and other treatments used in the management of acutely ill infants and children and ensuring that they are in keeping with best practice guidelines;
  • Use of the Broselow system of weight estimate and dosage calculation throughout the hospital where paediatric patients receive care.
  • Approach to and knowledge of common causes of convulsive status epilepticus, principles of management and indicated investigations.

Differential Diagnosis

Issues with differential diagnosis were identified:

  • Use of diuretics in child with congenital heart disease;
  • Wheezing in a child with heart disease.


Documentation issues included:

  • Communication and documentation of concerns raised by the family.


Transport/transfer issues included:

  • Role for the critical care transport of acutely ill children;
  • Potential opportunity for primary care paramedics to provide benzodiazepines for status epilepticus in the pre-hospital setting;
  • Understanding the role of medical handover and transfer of care between Physicians;
  • Opportunity for emergency medical services to inform their approach to Advanced Care Paramedic deployment.