Chief Coroner's Maternal and Perinatal Death Review Committee Releases Annual Report
Lessons Learned From Reviewing Maternal and Perinatal Deaths
Ministry of Community Safety and Correctional Services
The Maternal and Perinatal Death Review Committee (MPDRC) today released a report reviewing 41 cases from 2010, resulting in 83 recommendations designed to prevent future similar deaths and generally improve the quality of obstetrical and neonatal care in Ontario.
The committee, established in 1994 by the Office of the Chief Coroner, assists with the investigation and review of cases and develops recommendations aimed at preventing maternal (including during pregnancy and the post-natal period), stillbirth and neonatal deaths. All maternal deaths that occurred in 2010 were included in the report, as well as stillbirths and neonatal deaths where the family, coroner or regional supervising coroner raised concerns about the care received by the mother and/or child. Each year, the MPDRC releases an annual report that includes detailed summaries of the cases reviewed, recommendations made and a basic statistical analysis. Obstetrical care providers (including obstetricians, neonatologists, nurses, midwives, family physicians, anaesthetists, etc.) from across the province learn from case studies presented in these reports and promote the implementation of suggested recommendations. Of the 41 cases reviewed from 2010, 11 cases (resulting in 15 recommendations) related to maternal deaths, 19 cases (resulting in 48 recommendations) related to neonatal deaths and 11 cases (resulting in 20 recommendations) related to stillborns.
By sharing the recommendations generated by the Maternal and Perinatal Death Review Committee with the general public and the obstetrical care stakeholder community, we can collectively work towards addressing recurring issues and trends with a goal of preventing future similar deaths and improving the quality of obstetrical services in Ontario."
Dr. Rick Mann