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 anaesthesiology, pathology, neonatology and family medicine.  Representatives from the Society of Obstetricians and Gynaecologists have been instrumental in guiding the MPDRC on collaborative efforts to promote positive changes in obstetrical change across not only Ontario, but also Canada. 

Since its inception, the committee has reviewed a total of 464 cases and generated 795 recommendations towards the prevention of stillbirths and deaths involving mothers and neonates. In 2019, 34 cases were reviewed and 49 recommendations were made. The top areas of concern identified in recommendations made in 2019 related to obstetrical care providers, communications/documentation and diagnosis/testing.

Copies of full, redacted reports are available to the public by contacting occ.inquiries@ontario.ca.

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.

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. I would like to acknowledge the assistance of Ms. Kathy Kerr, Executive Lead of the MPDRC.

It is my privilege to present to you the 2019 Annual report of the MPDRC. 

Rick Mann, MD, CCFP, FCFP
Chair, Maternal and Perinatal Death Review Committee