The purpose of the PSRC is to assist the Office of the Chief Coroner (OCC) in the investigation and review of healthcare-related deaths where system-based errors or issues appear to be a major factor. The PSRC develops recommendations aimed at preventing similar future deaths, which are sent to the relevant agencies and organizations by the Chief Coroner for Ontario, through the Chair of the committee. The patient and public safety mandate of the OCC is derived from the Coroners Act:

Chief Coroner and duties

3. (1) The Lieutenant Governor in Council may appoint a coroner to be Chief Coroner for Ontario who shall,

(d) Bring the findings and recommendations of coroners’ investigations and coroners’ juries to the attention of appropriate persons, agencies and ministries of government;

Disclosure to the public

18. (4) The Chief Coroner shall bring the information collected during a coroner’s investigation and the investigation’s findings and recommendations, which may include personal information as defined in the Freedom of Information and Protection of Privacy Act, to the attention of the public, or any segment of the public, if the Chief Coroner reasonably believes that it is necessary in the interests of public safety to do so. 2018, c. 3, Sched. 6, s. 7 (1).

In the context of the PSRC, the use of the word “error” does not imply blame or responsibility on the part of any individual or organization. For the purposes of this committee, “error” is defined as a system design characteristic that either permits unintended adverse events to occur (latent error) or does not detect deviations from the intended path of care (active error). System design would include not only the design of care processes, but also access to care management (such as delays in receiving care). The presence of such errors does not mean that an individual or organization should be assigned blame or responsibility for an unintended outcome. The mandate of the PSRC, like that of the OCC, is one of fact-finding, not fault-finding.

The aims and objectives of the PSRC are:

  1. To provide expert opinion about the cause and manner of death in healthcare-related cases where systems-based errors appear to be a major factor.
  2. To assist coroners to improve the investigation of deaths within, or arising from, the health care system in which systems-based errors appear to have occurred.
  3. To stimulate educational activities for professionals through identification of systemic problems, referral to appropriate agencies for action, collaboration with professional regulatory bodies and the dissemination of an annual report. Emphasis will be placed on speedy dissemination of information.
  4. To provide expert evidence at inquests on request.
  5. To conduct or promote research, where appropriate.
  6. To undertake random or directed reviews when requested by the chairperson.
  7. To help identify the presence or absence of systemic issues, problems, gaps, or shortcomings of each case to facilitate appropriate recommendations for prevention.

Structure and size

The committee membership consists of respected practitioners from various disciplines related to health care. The membership is balanced to reflect wide and practicable geographical representation and representation from all levels of institutions, including teaching centres, to the extent possible. Other individuals with specialized knowledge or expertise are invited to participate in committee reviews when required and at the discretion of the chairperson.

The committee membership, and its balance, is reviewed regularly by the chairperson and by the chief coroner, as requested.