Historically, issues or concerns relating to patient safety that were identified during a coroner’s investigation may have led to individual recommendations being generated by the investigating coroner, or to a public review of the circumstances surrounding the death through a coroner’s inquest. The complexity of cases involving patient safety issues, however, often requires specialized knowledge and expertise to fully understand the intricacies of the circumstances of the death. Inquests may take place several years after a death and it may be challenging for a jury comprised of members of the public to fully grasp the complex medical details to make practical recommendations aimed at preventing similar deaths in the future.

The Patient Safety Review Committee (PSRC) was established in 2005 to address the need for specialized knowledge and expertise in helping to expedite the review of coroners’ cases with actual or perceived systemic patient safety implications, and where possible, to make recommendations to prevent future similar deaths.