Full, redacted versions of reports and responses to recommendations are available to the public by contacting: occ.inquiries@ontario.ca.

Questions and comments regarding this report may be directed to:
Maternal and Perinatal Death Review Committee
Office of the Chief Coroner
25 Morton Shulman Avenue
Toronto, ON M3M 0B1
occ.inquiries@ontario.ca.

Message from the Chair

The Maternal and Perinatal Death Review Committee (MPDRC), together with its predecessor, the Obstetrical Care Review Committee, has been providing expert advice to coroner’s investigations in Ontario since 1994.

The MPDRC reviews all maternal deaths in Ontario that are reported to the coroner system that occur during pregnancy, during delivery or immediately following delivery up to 42 days post-partum. Deaths after 42 days post-delivery are reviewed if there are concerns that the cause of death is directly related to the pregnancy or a complication of the pregnancy.

The committee also reviews stillbirths and perinatal deaths investigated by the Chief Coroner’s Office where issues have been identified by the family, the investigating coroner or the Regional Supervising Coroner.

The MPDRC is comprised of well-respected and experienced experts representing the fields of obstetrics, maternal-fetal medicine, midwifery, perinatal nursing, obstetrical anesthesiology, pathology, neonatology, and family medicine. Representatives from the Society of Obstetricians and Gynaecologists of Canada have been instrumental in guiding the MPDRC on collaborative efforts to promote positive changes in obstetrics across not only Ontario, but also Canada.

Since its inception, the committee has reviewed a total of 487 cases and generated 834 recommendations towards the prevention of stillbirths and deaths involving mothers and neonates. In 2020, 23 cases were reviewed, and 39 recommendations were made. The top areas of concern identified in recommendations made in 2020 related to obstetrical care providers, transfer, communications/documentation, diagnosis/testing, policy/procedures, and education/training.

As we strive towards reducing similar deaths and improving the quality of care provided to mothers and infants, the identification of these trends will help guide the direction of future recommendations and prompt action by stakeholders within the obstetrical care community.

Copies of full, redacted reports are available to the public by contacting occ.inquiries@ontario.ca. It is the hope of this committee that these reports may be used to educate and help improve obstetrical care.

It is an honour to participate in the work of the MPDRC and I am grateful for the commitment of its members to the people of Ontario. As I became the Chair of this committee only at the end of 2020, the substantial contribution of Dr. Rick Mann who was the Chair of the MPDRC from 2011–2020 must be recognized. His work towards improving maternal and perinatal health over the years is much appreciated. I would like to acknowledge the assistance of Ms. Kathy Kerr, Executive Lead of the MPDRC. Without her organizational expertise the reviews and this report would not be possible.

It is my privilege to present to you the 2020 Annual report of the MPDRC. 

Louise McNaughton-Filion, MD CCFP(EM), FCFP CCPE
Chair, Maternal and Perinatal Death Review Committee (MPDRC)
Regional Supervising Coroner
East Region — Ottawa Office