Chart 1 shows that from 2015 to 2018 inclusive, the PSRC reviewed a total of 28 cases and made 139 recommendations aimed towards the prevention of future deaths. Of the cases reviewed, 18 involved natural deaths, four were accidental deaths, five were suicides and one was undetermined. There were an equal number of female and male decedents in the cases reviewed.

The number of recommendations made ranged from one to 11, with an average of five recommendations per case. There were no cases where the PSRC did not make a recommendation.

Chart 1: Summary of cases reviewed by PSRC 2015–2018
Year Number of cases Number of recommendations Natural Accident Homicide Suicide Undetermined Female Male
2015 5 28 4 null null 1 null 4 1
2016 6 24 2 1 null 3 null 4 2
2017 9 52 7 null null 1 1 3 6
2018 8 35 5 3 null null null 3 5
Total 28 139 18 4 0 5 1 14 14

A summary of all cases reviewed by the PSRC from 2015–2018, together with the recommendations made, is included as the Appendix.

Chart 2: Percent of recommendations with theme present (PSRC 2015–2018)

Chart 2 demonstrates that 53% of all recommendations made by the PSRC between 2015–2018 were focused on medical and nursing management. Following this, 42% of the recommendations touched on communications and documentation and 36% on medication (pharmacy) / equipment issues.