Maternal and Perinatal Death Review Committee Annual Report 2015
Office of the Chief Coroner
Maternal and Perinatal Death Review Committee
Annual Report 2015
Committee Membership (2015)
Statistical Overview (2004-2015)
Executive Summary of Cases Reviewed in 2015
Lessons Learned from MPDRC Reviews
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. Information from these reviews is provided to Health Canada to assist in identifying and preventing maternal deaths in Canada.
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, pediatrics and family medicine.
Since its inception, the committee has reviewed a total of 351 cases and generated 653 recommendations towards the prevention of stillbirths and deaths involving mothers and neonates. In 2015, 24 cases were reviewed and 52 recommendations were made. The top five areas of concern identified in recommendations made in 2015 relate to: policy and procedure; diagnosing and testing; medical and nursing issues; communication/documentation and quality of care reviews.
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 2015 Annual report of the MPDRC.
Rick Mann, MD, CCFP, FCFP
Chair, Maternal and Perinatal Death Review Committee
Dr. Sharon Dore
Society of Obstetricians and Gynecologists of Canada Representative
Dr. Michael Dunn
Neonatologist (Level 3)
Dr. Karen Fleming
Family Physician (Level 3)
Dr. Robert Gratton
Maternal Fetal Medicine
Dr. Steven Halmo
Obstetrician (Level 2)
Ms. Susan Heideman
Dr. Robert Hutchison
Obstetrician (Level 3)
Dr. Sandra Katsiris
Ms. Kathy Kerr
Ms. Michelle Kryzanauskas
Dr. Dilipkumar Mehta
Paediatrician (Level 2)
Ms. Linda Moscovitch
Dr. Toby Rose
Dr. Gillian Yeates
Obstetrician (Level 1)
Dr. Rick Mann
Regional Supervising Coroner
- In 1994, the Office of the Chief Coroner established the Obstetrical Care Review Committee. In 2004, the name of the committee was changed to the Maternal and Perinatal Death Review Committee.
- The purpose of the MPDRC is to assist the Office of the Chief Coroner in the investigation, review and development of recommendations directed towards the prevention of future similar deaths relating to all maternal deaths (irrespective of cause) and stillbirths and neonatal deaths where the family, coroner or Regional Supervising Coroner have concerns about the care that the mother or child received.
- Since 2004, the MPDRC has reviewed 351 cases and generated 653 recommendations aimed towards the prevention of future similar deaths.
- On average, 29 cases and 54 recommendations are made each year by the MPDRC.
- The top areas of concern identified in recommendations made from 2004-2015 relate to: medical and nursing issues; policy and procedures; communications/documentation; and diagnosis and testing (including electronic fetal monitoring).
- In 2015, 24 cases were reviewed and 52 recommendations were made.
- Of the 24 cases reviewed in 2015, five were maternal, 15 were neonatal and four were stillborn.
In 1994, the Office of the Chief Coroner established the Obstetrical Care Review Committee. In 2004, the name of the committee was changed to the Maternal and Perinatal Death Review Committee.
The purpose of the MPDRC is to assist the Office of the Chief Coroner in the investigation, review and development of recommendations directed towards the prevention of future similar deaths relating to all maternal deaths regardless of cause. This includes all deaths during pregnancy and the post-natal period (which is considered to be up to 42 days after delivery). Any deaths after 42 days and up to 365 days post-delivery are reviewed if the cause of death is directly related to the pregnancy or a complication of the pregnancy.
The committee reviews stillbirths and neonatal deaths where the family, coroner or Regional Supervising Coroner have concerns about the care that the mother or child received.
Findings of legal responsibility or conclusions of law are not permitted under the Coroners Act.
Definition of Maternal Deaths, Stillbirths, Perinatal and Neonatal Deaths
The MPDRC reviews the deaths of all women who died “during pregnancy and following pregnancy in circumstances that could reasonably be attributed to pregnancy.” Deaths involving women who are pregnant, but where the death was not attributed to pregnancy are noted for statistical purposes only and a condensed, executive review (as opposed to full committee review) is conducted.
Maternal deaths are classified by the following criteria:
- Antepartum – during pregnancy at >20 weeks gestation
- Intrapartum - during delivery or immediately following delivery
- Postpartum - < 42 days after delivery
This committee does not review late maternal deaths occurring >42 days unless the cause of death is directly related to the pregnancy or a complication of the pregnancy.
Stillbirth is defined as the complete expulsion or extraction from the mother of a product of conception either after the 20th week of pregnancy or after the product of conception has attained the weight of 500 grams or more, and where after such expulsion or extraction there is no breathing, beating of the heart, pulsation of the umbilical cord or movement of voluntary muscle. (source: Vital Statistics Act of Ontario.)
Perinatal deaths are defined as deaths during, at the time of, or shortly after birth, including home births.
Neonatal deaths are defined as deaths within the first seven days after birth.
Aims and Objectives
- To assist coroners in the Province of Ontario to investigate maternal and perinatal deaths and to make recommendations that may prevent similar deaths.
- To provide expert review of the care provided to women during pregnancy, labour and delivery, and the care provided to women and newborns in the immediate postpartum period.
- To provide expert review of the circumstances surrounding all maternal deaths in Ontario, in compliance with the recommendations of the Special Report on Maternal Mortality and Severe Morbidity in Canada. (Special Report on Maternal Mortality and Severe Morbidity in Canada, Health Canada, 2004.)
- To inform doctors, midwives, nurses, institutions providing care to pregnant and postpartum women and newborns, and relevant agencies and ministries of government about hazardous practices and products identified during case reviews.
- To produce an annual report that can be made available to doctors, nurses and midwives providing care to mothers and infants, and hospital departments of obstetrics, midwifery, radiology/ultrasound, anaesthesia and emergency for the purpose of preventing future deaths.
- To help identify the presence or absence of systemic issues, problems, gaps, or shortcomings of each case to facilitate appropriate recommendations for prevention.
- To help identify trends, risk factors, and patterns from the cases reviewed to make recommendations for effective intervention and prevention strategies.
- To conduct and promote research where appropriate.
- To stimulate educational activities through the recognition of systemic issues or problems and/or referral to appropriate agencies for action.
- Where appropriate, to assist in the development of protocols with a view to prevention.
- Where appropriate, to disseminate educational information.
Note: All of the above described objectives and attendant committee activities are subject to the limitations imposed by the Coroners Act of Ontario and the Freedom of Information and Protection of Privacy Act.
Structure and Size
The committee membership consists of respected practitioners in the fields of specialty including: obstetrics, family practice, specialty neonatology, community pediatrics, pediatric and maternal pathology, anesthesiology, midwifery and obstetrical nursing. The membership is balanced to reflect wide and practicable geographical representation as well as representation from all levels of institutions providing obstetrical care including teaching centers to the extent possible. The chairperson will be a Deputy Chief Coroner or Regional Supervising Coroner or other person designated by the Chief Coroner.
Other individuals are invited to the committee meetings as necessary on a case by case basis (e.g. investigating coroner, Regional Supervising Coroner, other specialty practitioner relevant to the facts of the case, etc.).
Investigating coroners and Regional Supervising Coroners refer cases to the committee for review. At least one member of the committee reviews the information submitted by the coroner and then presents the case to the other members. After discussion by the committee, a final case report is written consisting of a summary of events, discussion and recommendations (if any), intended to prevent deaths in similar circumstances. The report is then sent to the referring Regional Supervising Coroner who may conduct further investigation (if necessary). Recommendations are distributed to agencies and organizations which may be in a position to effect the implementation of such recommendations. Organizations are asked to respond back within one year with the status of implementation of recommendations.
Where a case presents a potential or real conflict of interest for a committee member, the committee reviews the case in the absence of the member with the conflict.
When a case requires expertise from another discipline, an external expert reviews the case, attends the meeting and participates in the discussion and drafting of recommendations, if necessary.
This committee is advisory to the coroner system and will make recommendations to the Chief Coroner through the chairperson.
The consensus report of the committee is limited by the data provided. Efforts are made to obtain all relevant data.
The MPDRC case reports are prepared for the Office of the Chief Coroner and are therefore governed by the provisions of 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. Cases referenced in the annual report do not include identifying details.
It is important to acknowledge that these reports rely upon a review of the written records. The Coroner/Regional Supervising Coroner conducting the investigation may have received additional information that rendered one or more of the committee's conclusions invalid. Where a fact was made known to the chair of the committee prior to the production of the annual report, the case review was revised to reflect these findings.
Recommendations are made following a careful review of the circumstances of each death; they are not intended to be policy directives and should not be interpreted as such.
This report of the activities and recommendations of the MPDRC is intended to provoke thought and stimulate discussion about obstetrical care and maternal and perinatal deaths in general in the province of Ontario.
The MPDRC (and previously the Obstetrical Care Review Committee) has generated recommendations since being established in 1994. Over time, not only has the committee evolved, but so too have medical technologies, policies, procedures and public and professional attitudes towards maternal and perinatal care in the province. In order to provide an analysis that is reflective of more current values and attitudes, the statistical analysis contained within this annual report will focus on cases reviewed and recommendations made since 2004.
From 2004-2015, the MPDRC has reviewed a total of 351 cases. Of these cases, 106 (30%) were maternal, 159 (45%) were neonatal and 86 (25%) were stillbirths. These numbers reflect the policy of the Office of the Chief Coroner to review all maternal deaths. Deaths involving women who are pregnant, but where the pregnancy did not cause or contribute to the death, are noted and undergo an “executive” review, but do not undergo formal review (and thus are not reflected in these statistics). The executive review is conducted by a core team of representatives of the MPDRC and includes an analysis of the circumstances surrounding the maternal death. The results of the review are discussed with the full committee for any additional investigation or comment.
Neonatal and stillbirth reviews are conducted only when the family, investigating coroner or Regional Supervising Coroner have concerns about the care that the mother or child received.
The number of cases noted in Chart One is based on the year the case was reviewed, which, in many cases, is not the same year in which the death actually occurred.
Chart One: MPDRC - # of Cases Reviewed (2004-2015)
|Total # of cases reviewed||30||30||25||27||30||46||41||30||32||26||10||24||351|
Chart One indicates that the total number of cases reviewed from 2004-2015 has varied from a low of 10 cases in 2014, to a high of 46 cases in 2009. This variance is likely reflective of committee administrative practices (e.g. time required for processing of review materials and compilation of final reports).
Graph One: Total number of cases reviewed by the MPDRC based on year (2004-2015)
Graph One demonstrates how the number of cases reviewed from 2004-2015 has remained relatively consistent, with a low in 2014 due to committee administrative issues. On average, the MPDRC reviews 29 cases per year.
Graph Two: Number of cases reviewed based on type of case (2004-2015)
Graph Two demonstrates that, overall, from 2004-2015, the majority of cases reviewed each year are neonatal deaths, followed by maternal deaths.
Chart Two: MPDRC - # of Recommendations (2004-2015)
|Total # of Recommendations||56||71||58||36||46||69||83||47||76||31||28||52||653||-||54|
Chart Two indicates that the MPDRC has generated a total of 653 recommendations from 2004-2015. From this total, 117 (18%) were related to maternal cases, 361 (55%) from neonatal cases and 175 (27%) from stillbirth cases. Consistently over the years, the majority of cases and recommendations relate to reviews of neonatal deaths. On average, 54 recommendations are made per year.
Upon reviewing the recommendations that have been made, certain areas of concern have consistently emerged over time. The following general areas of concern have been identified:
- medical (e.g. medical or nursing decisions)
- policy and procedure (e.g. adherence or development of policy and procedures)
- communication/documentation (e.g. sharing and documenting information)
- quality (e.g. quality of care reviews)
- diagnosis and testing (e.g. interpretation of laboratory results)
- diagnosis and testing – specifically electronic fetal monitoring (EFM) (e.g. interpretation of results)
- education/training (e.g. continuing education)
- resources (e.g. access and allocation of resources)
- transfer (e.g. movement of patients)
- other (e.g. referral to another committee for review)
Graph Three: Number of recommendations based on type of case 2004-2015
Graph Three demonstrates that from 2004-2015, the majority of recommendations generated each year pertain to neonatal cases.
Chart Three: MPDRC – Number and percentage of recommendations based on area of concern/theme and type of case (2004-2015)
|Maternal||Neonatal||Stillborn||Total||% of Total|
|Policy and procedure||28
|Diagnosis and testing||3
|Diagnosis and testing - EFM||1
*Some recommendations touch on more than one theme.
Chart Three demonstrates that 23% of all recommendations made by the MPDRC from 2004-2015 relate to improving or addressing medical/nursing issues. An additional 20% of the recommendations pertain to the development of, or adherence to, policies and procedures and 15% to communication and/or documentation and in particular, the timely and accurate sharing of information between healthcare providers and with the patient.
Chart three also demonstrates the following key areas (based on type of case and theme):
- 10% of all recommendations from neonatal cases had a medical/nursing theme
- 10% of all recommendations from neonatal cases had a policy and procedure theme
- 9% of all recommendations from neonatal cases had a communication/documentation theme
One area of specific concern that has been identified over the past few years relates to the use of electronic fetal monitoring (EFM) technology, how EFM results are interpreted by obstetrical care providers and what follow-up actions are taken in response to the findings. From 2004-2015, there have been 76 recommendations made specifically pertaining to EFM.
Cases reviewed by the MPDRC in 2015 may involve deaths that occurred in previous years.
Total number of cases reviewed (i.e. full reviews): 24
Total number of recommendations: 52
Number of maternal full case reviews: 5
Number of maternal executive reviews: 7
Number of recommendations from the maternal deaths reviewed: 14
Number of neonatal cases reviewed: 15
Number of recommendations from the neonatal deaths: 29
Number of stillborn cases reviewed: 4
Number of recommendations from the stillborn cases: 9
A summary of all cases reviewed and subsequent recommendations made in 2015, is included as Appendix A.
This past year, three out of five maternal deaths reviewed by the committee involved post-partum haemorrhages (PPH). This requires a high index of suspicion from all care providers including obstetrical care providers as well as post anaesthesia care unit staff who may have infrequent call to care for a post-partum patient. Ongoing visible blood loss may not be indicative of the true blood loss. The now empty uterus can fill with blood and hide the true extent of blood loss. Uterine atony is the most common and important cause of PPH. Normally healthy women are able to compensate for significant blood loss until a critical level is reached.
Whenever possible, treatment should be a team approach with the use of a combination of uterotonics, blood products and investigations to identify the source and severity of the blood loss. Centres providing obstetrical care should consider establishing massive transfusion protocols (MTP) to initiate early on so as not to fall behind replacing blood loss. Cyropercipitate should be considered early in the resuscitation process as pregnant women are already in a hypocoaguable state.
Another topic which played a role in stillbirths, neonatal and maternal deaths has been an increased body mass index (BMI) and pregnancy. BMI should be calculated at entry into obstetrical care and ideally be below 25 kg/m2. Elevated BMI has been associated with increased risk of congenital abnormalities of the fetus, maternal complications such as cardiac disease, pulmonary disease as well as gestational hypertension and diabetes. Complications during labour and delivery, including analgesia, also increase with an elevated BMI. Consideration should be given to obtaining an anaesthetic consultation during pregnancy in women with an elevated BMI (i.e. > 25 -30 kg/m2) to plan analgesic/anaesthetic care plans during labour and delivery if they are needed. It is better to know and prepare for a possible difficult airway to manage prior to a crash Caesarian section for fetal distress or failure to progress in labour.
Summary of 2015 Case Reviews
|EX-01||Maternal - Executive||The decedent was a 40-year-old woman who was admitted to hospital at 29 weeks gestation with a one month history of fever, lethargy and headache. She was found to have an enlarged liver with elevated liver function tests and pancytopenia. The cause of death was noted as Hemophagocytosis Syndrome as a consequence of Systemic Lupus Erythematosus.||None.|
|EX-02||Maternal - Executive||The decedent was a 20-year-old woman who died at eight months gestation. The cause of death was determined to likely be a cardiac arrhythmia of genetic cause.||-||None.|
|EX-03||Maternal - Executive||The decedent was a 38-year-old woman who died of idiopathic peripartum cardiomyopathy after being admitted to hospital emergency at 36 weeks gestation.||None.|
|EX-04||Maternal - Executive||The decedent was a 37-year-old woman who died at 11 weeks gestation from sudden unexpected death in epilepsy (SUDEP).||None.|
|EX-05||Maternal - Executive||The decedent was a 27-year-old woman in the early stages of pregnancy who committed suicide.||None.|
|EX-06||Maternal - Executive||The decedent was a 33-year-old G3P0A2 who died at 24 weeks gestation from hypoxic-ischemic encephalopathy, myocardial infarction and recent arterial dissections of both the left anterior descending coronary artery and the right coronary artery.||None.|
|EX-7||Maternal - Executive||The decedent was a 38-year-old woman who had been receiving fertility treatments. She was found deceased in her bed and there was decomposition of her remains. The cause of death was unascertained and the manner of death was undetermined.||None.|
|M-01||Maternal||The decedent was a 38-year-old G2P0 who died after giving birth at 39 weeks gestation from severe hemorrhagic shock caused by post-partum hemorrhage. The cause of the post-partum hemorrhage was uterine atony.||Quality||
|M-02||Maternal||The decedent was a 36-year-old G2A1 who died after giving birth from hemorrhagic and thromboembolic complications and gestational hypertension with preeclampsia.||Medical, diagnosis/testing, policy/procedures, communications, quality||
|M-03||Maternal||The decedent was a 25-year-old G1 who died after giving birth at 40 weeks gestation from hemorrhagic shock secondary to uterine atony.||Medical, policy/procedures, communications,||
|M-04||Maternal||The decedent was a 26-year-old woman who was five weeks postpartum when she died of pulmonary thromboembolism. Elevated BMI was a risk factor.||No recommendations.|
|M-05||Maternal||The decedent was a 33-year-old woman who died from hemorrhagic shock from an unsuspected ruptured right tubal pregnancy.||Diagnosis/testing, policy/procedures||
|N-01||Neonatal||The decedent was an eight-hour-old male infant born at 34 weeks four days gestation who died from perforation of the left ventricular wall and intraventricular septum by a left chest tube. The placenta showed evidence of chorioamnionitis and fetal inflammatory response.||Diagnosis/testing||Care providers are reminded to perform imaging prior to chest tube insertion if the condition of the infant allows.|
|N-02||Neonatal||The decedent was a nine-day-old male infant born at 37 weeks one day gestation who died from hypoxic-ischemic encephalopathy due to perinatal asphyxia of undetermined etiology with multiple placental abnormalities as potential contributing factor.||No recommendations.|
|N-03||Neonatal||The decedent was a one-hour-old male infant born at 33 weeks gestation who died from perinatal asphyxia due to (a) pulmonary hypoplasia (b) obstructive uropathy from membranous obstruction of the urethra.||Medical, quality, communications, diagnosis/testing,||
|N-04||Neonatal||The decedent was a two-day-old male infant born at 40 weeks gestation who died from severe hypoxic-ischemic encephalopathy due to (a) multiple organ dysfunction (b) maternal uterine rupture. The mother was a 36-year-old G5T1P2A1L4 who was high risk due to Crohn's disease, obesity (BMI 35) and had a history of substance abuse (daily tetrahydrocannabinol (THC) use).||No recommendations.|
|N-05||Neonatal||The decedent was a male infant born at 40 weeks three days gestation who died at 43 minutes of age from obstructed labour in association with macroencephaly. The mother was a 31-year-old G1P0.||Policy/procedures, quality||
|N-06||Neonatal||The decedent was a female infant who died at three hours of age. There was no anatomical cause of death. The mother was a 40-year-old G2P1. Induction was planned at 39 weeks because of advanced maternal age.||Policy/procedures, training, diagnosis/testing - EFM||
|N-07||Neonatal||The decedent was a male infant born at 41 weeks gestation who died at four days of age from hypoxic ischemic encephalopathy. The mother was a 35-year-old G4T2A1L2.||Medical, diagnosis/testing, policy/procedures||
|N-08||Neonatal||The decedent was a male infant born at 36 weeks and one day gestation who died at 27 minutes of age from bilateral diffuse severe renal dysplasia. The mother was a 32-year-old G5P3A1.||No recommendations.|
|N-09||Neonatal||The decedent was a female infant born at 41 weeks and four days gestation who died at 19 days of age from perinatal asphyxia. Contributing factors: intrauterine growth retardation, placental fetal thrombotic vasculopathy, maternal hypertension. The mother was a 31-year-old G1 with a history of chronic controlled hypertension.||Medical||
|N-10||Neonatal||The decedent was a female infant born at 33 weeks and three days gestation who died at one month of age following an episode of severe gram negative septicemia with shock and coagulopathy. The mother was a 36-year-old G6P0. The pregnancy was achieved by in vitro fertilization (IVF).||No recommendations.|
|N-11||Neonatal||The decedent was a male infant born at 40 weeks gestation who died at one month of age from anoxic brain injury due to birth trauma. Placental examination indicated acute chorionamnionitis and chorionic vasculitis. The mother was a 29-year-old G3A2 with two previous early spontaneous losses.||The hospital conducted an internal review and produced recommendations. No recommendations from MPDRC.|
|N-12||Neonatal||The decedent was a female infant born at 39 weeks and six days gestation who died at 24 hours of age from hypoxic ischemic encephalopathy.||Diagnosis/testing – EFM, medical, policy/procedures||
|N-13||Neonatal||The decedent was a male infant born at 40 weeks gestation who died at two days of age from hypoxic-ischemic encephalopathy due to intrauterine hypoxic-ischemic stress, cause unknown, preceding labour and delivery. The mother was a 29-year-old G1P0.||Diagnosis/testing – EFM, communications||
|N-14||Neonatal||The decedent was a male infant born at 40 weeks and two days gestation who died at 24 hours of age from Group B Streptococcal sepsis. The mother was a G4P3.||Transfer, quality, diagnosis/testing, training, policy/procedures||
|N-15||Neonatal||The decedent was a female infant born at 39 weeks and three days gestation who died at 11 hours of age. The cause of death was undetermined. The mother was a 35-year-old G1P0 medical history of human papillomavirus and bacterial vaginosis.||diagnosis/testing, resources||The College of Midwives should consider neonatal point-of-care glucose testing equipment as essential.|
|S-01||Stillbirth||The mother was a 19-year-old G1P0 who presented in labour at 39 weeks gestational age. The cause of death for this stillborn was determined to be a cord complication. Placental insufficiency was a contributing factor.||Policy/procedures, communications, training, quality||
|S-02||Stillbirth||The mother was a 41-year-old G2P1. The immediate cause of death was noted to be: placental abruption and uterine tear due to uterine hyperstimulation of labor induction with advanced maternal age as a contributing factor.||No recommendations.|
|S-03||Stillbirth||The mother was a 31-year-old G1P0. The cause of death was undetermined.||
|S-04||Stillbirth||The mother was a 31-year-old G2T1P0A0L1. Cause of death was acute perinatal asphyxia of undetermined etiology.||Diagnosis/testing – EFM, transfer||