Message from the Chair

This is a report of cases reviewed by the Office of the Chief Coroner Patient Safety Review Committee from 2015-2018, inclusive.

Over the past four years, the committee completed 28 reviews of deaths that involved the presence of systemic issues related to the provision of care. From the cases reviewed, the committee made a total of 139 recommendations aimed at preventing future deaths.

Examining deaths from the perspective of enhancing patient safety is an important step in preventing avoidable deaths. It is through the analysis of these cases that preventative approaches can be developed and enhanced to help prevent future morbidity and mortality.

The PSRC is composed of regular and invited members who help contribute to an open, nonjudgmental analysis of cases. It is through the analysis, discussion and knowledge of the healthcare system in Ontario that the recommendations are developed. The quality of the recommendations is our goal, not the number. Through effective, clearly expressed recommendations, there can be a meaningful opportunity for further learning and change within the healthcare system. This, in turn, can support change that is predicated on enhancing patient safety.

Systemic learning is directed at the goal of prioritizing care of the patient (including their family/friends). This can only be achieved through the unbiased and open analysis of organizational policies, resource provision and utilization, use of evidence-based care provision protocols, patient-centred communication policies, and an educationally-focused incident reporting, analysis, and management system. These processes, along with appropriate preventative and mitigation-based processes, will help ensure that healthcare provision in our province is resilient, responsive and effective for today and the future.

On behalf of the committee, thank you for your interest in patient safety, and in the work of the Patient Safety Review Committee.

Reuven Jhirad MD MPH CCFP FCFP
Deputy Chief Coroner
Chair, Patient Safety Review Committee