• In 1994, the Office of the Chief Coroner established the Obstetrical Care Review Committee.  In 2004, the name of the committee was changed to the Maternal and Perinatal Death Review Committee.
  • The purpose of the MPDRC is to assist the Office of the Chief Coroner in the investigation, review and development of recommendations directed towards the prevention of future deaths relating to all maternal deaths (irrespective of cause) and stillbirths and neonatal deaths where the family, coroner or Regional Supervising Coroner have concerns about the care that the mother or child received.
  • Since 2004, the MPDRC has reviewed 464 cases and generated 795 recommendations aimed towards the prevention of future deaths.
  • On average, 29 cases are reviewed and 50 recommendations are made each year by the MPDRC.
  • The top areas of concern identified in recommendations made from 2004-2019 relate to: obstetrical care provider issues ; policy and procedures; communications/documentation; and diagnosis and testing (including electronic fetal monitoring). 
  • In 2019, 34 cases were reviewed and 47 recommendations were made.
  • Of the 34 cases reviewed in 2019, 21 were maternal (13 executive reviews and eight full reviews), 11 were neonatal and two were stillborn. 
  • Deaths involving women who are pregnant, but where the pregnancy did not cause or contribute to the death, are noted and undergo an “executive” review.  Maternal deaths involving a known complication of pregnancy (e.g. pulmonary embolism) and where there are no concerns regarding the care provided to the mother, may also undergo an executive review. The executive review is conducted by a core team of representatives of the MPDRC and includes an analysis of the circumstances surrounding the maternal death. The results of the review are discussed with the full committee for any additional investigation or comment (commencing in the 2017 Annual Report, executive reviews are included in the statistics for total number of reviews conducted).