Overview

The Paediatric Death Review Committee (PDRC) – Medical is a multi-disciplinary committee that consists of specialized practitioners in paediatric pathology, paediatric critical care, community paediatrics, and paediatric emergency medicine. When indicated, the committee is assisted by paediatric subspecialists. The membership is balanced to reflect Ontario’s geography and includes differing levels of institutions that provide paediatric care and teaching centres, when possible.

Medical reviewers analyze and consider the medical issues involved in the time preceding a child or youth’s death to gain a better understanding of the circumstances of the death. Case referrals for committee evaluation include medically complex deaths when there are concerns regarding the medical care or if there are questions about the clinical diagnosis, cause and/or manner of death.

Review process

Case assignment occurs by aligning the practice profile and expertise of the committee members with the circumstances of the death. For example, paediatric deaths from a community setting will be reviewed by one of the community paediatricians. The review process involves analyzing the existing record of the young person. The record routinely includes medical records, the Coroner’s Investigation Statement, the report of the post-mortem examination, toxicology report, police report and other relevant documents.

At the committee meetings, the primary reviewer presents the findings to the members for discussion.  This provides an opportunity for discussion about issues that may have been identified through the review.  The committee may develop recommendations based on the findings of the review. The primary reviewer will compose a final report reflecting the committee’s consensus opinion. The report, which will include the cause and manner of death and any committee recommendations, is provided to the referring Regional Supervising Coroner. If the recommendations are systemic, the ministry, organization, agency, or individuals are notified by the Committee Chair. Since 2017, organizations have been asked to respond within six months of receiving the recommendations, which is consistent with the OCC’s approach to inquest recommendations.

Where a death review presents a potential or real conflict of interest for a committee member, that member does not participate in the review process.

Limitations

The PDRC-Medical death reports are prepared for the OCC and are governed by the Coroners Act, the Vital Statistics Act, the Freedom of Information and Protection of Privacy Act and the Personal Health Information and Protection of Privacy Act.

The consensus report of the committee is limited by the information provided. While efforts are made to obtain all relevant data, it is important to acknowledge that these reports are generated from a review of the written records. Sometimes, the coroner/Regional Supervising Coroner conducting the investigation may receive additional information not included in the records. Such information may render one or more of the committee's conclusions invalid.

It is pertinent to note that recommendations are made following a careful review of the circumstances of each death; they are not intended to be policy directives.