Maternal and Perinatal Death Review Committee 2016 Annual Report
Office of the Chief Coroner
Maternal and Perinatal Death Review Committee
2016 Annual Report
Message from the Chair
Committee Membership (2016)
Statistical Overview (2004-2016)
Executive Summary of Cases Reviewed in 2016
Lessons Learned from MPDRC Reviews
This report was prepared by Dr. Rick Mann, Chairperson of the Maternal and Perinatal Death Review Committee, and Ms. Kathy Kerr – Executive Lead – Committee Management.
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.
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, neonatology and family medicine.
Since its inception, the committee has reviewed a total of 368 cases and generated 691 recommendations towards the prevention of stillbirths and deaths involving mothers and neonates. In 2016, 17 cases were reviewed and 38 recommendations were made. The top areas of concern identified in recommendations made in 2016 related to policy and procedure and communications/documentation .
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 2016 Annual report of the MPDRC.
Rick Mann, MD, CCFP, FCFP
Chair, Maternal and Perinatal Death Review Committee
Dr. Sharon Dore
Society of Obstetricians and Gynaecologists 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
Neonatologist (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 377 cases and generated 691 recommendations aimed towards the prevention of future similar deaths.
- On average, 28 cases are reviewed and 53 recommendations are made each year by the MPDRC.
- The top areas of concern identified in recommendations made from 2004-2016 relate to: medical and nursing issues; policy and procedures; communications/documentation; and diagnosis and testing (including electronic fetal monitoring).
- In 2016, 17 cases were reviewed and 38 recommendations were made.
- Of the 17 cases reviewed in 2016, nine were maternal, 10 were neonatal and three were stillborn.
- 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.
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
- 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. Effective January 2017, organizations are being asked to respond back within six months.
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 2004-2016, the MPDRC has reviewed a total of 368 cases. Of these cases, 110 (30%) were maternal, 169 (46%) were neonatal and 89 (24%) 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 (2004-2016)
|Total # of cases reviewed||30||30||25||27||30||46||41||30||32||26||10||24||17||368||-||28|
Chart One indicates that the total number of cases reviewed from 2004-2016 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 (2004-2016)
Graph One demonstrates how the number of cases reviewed from 2004-2016 has remained relatively consistent, with a low in 2014 due to committee administrative issues. On average, the MPDRC reviews 28 cases per year.
Graph Two: Number of cases reviewed based on type of case (2004-2016)
Graph Two demonstrates that, overall, from 2004-2016, the majority of cases reviewed each year are neonatal deaths, followed by maternal deaths.
Chart Two: MPDRC - # of Recommendations (2004-2016)
|Total # of Recommendations made||56||71||58||36||46||69||83||47||76||31||28||52||38||691||-||53|
Chart Two indicates that the MPDRC has generated a total of 691 recommendations from 2004-2016. From this total, 118 (17%) were related to maternal cases, 393 (57%) from neonatal cases and 180 (26%) from stillbirth cases. Consistently over the years, the majority of cases and recommendations relate to reviews of neonatal deaths. On average, 53 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 2004-2016
Graph Three demonstrates that from 2004-2016, 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 (2004-2016)
|Area/Concern/Theme||Maternal||Neonatal||Stillborn||Total||% of Total|
|Medical/nursing||48 40%||69 17%||37 20%||154||22%|
|Policy and procedure||28 23%||81 20%||35 19%||144||20%|
|Communications/documentation||12 10%||66 16%||34 19%||112||16%|
|Quality||15 13%||34 8%||12 7%||61||9%|
|Diagnosis and testing||4 3%||54 13%||20 11%||78||11%|
|Diagnosis and testing - EFM||1 1%||50 12%||27 15%||78||11%|
|Education/Training||2 2%||23 6%||8 4%||33||5%|
|Resources||3 3%||14 3%||3 2%||20||3%|
|Transfer||5 4%||10 2%||5 3%||20||3%|
|Other||2 2%||2 0.5%||1 1%||5||1%|
*Some recommendations touch on more than one theme.
Chart Three demonstrates that 22% of all recommendations made by the MPDRC from 2004-2016 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 16% 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):
- 17% of all recommendations from neonatal cases had a medical/nursing theme
- 20% of all recommendations from neonatal cases had a policy and procedure theme
- 16% 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 2004-2016, there have been 78 (11% of the total) recommendations made specifically pertaining to EFM.
Cases reviewed by the MPDRC in 2016 may involve deaths that occurred in previous years.
Total number of cases reviewed (i.e. full reviews): 17
Total number of recommendations: 38
Number of maternal full case reviews: 4
Number of maternal executive reviews*: 9
Number of recommendations from the maternal deaths reviewed: 1
Number of neonatal cases reviewed: 10
Number of recommendations from the neonatal deaths: 32
Number of stillborn cases reviewed: 3
Number of recommendations from the stillborn cases: 5
* 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.
A summary of all cases reviewed and subsequent recommendations made in 2016, is included as Appendix A.
Over the years, the MPDRC has identified trends in issues identified through the review process. Consistently, the key areas where concerns continue to be identified relate to medical/nursing issues, policies and procedures and communication/documentation. Responding to fetal distress, differentiating between fetal and maternal heart rates, communication between obstetrical care providers and transportation, are specific areas where concerns continue to be identified.
The MPDRC continues to strive to help identify the presence or absence of systemic issues, problEMS, gaps, or shortcomings in order to facilitate appropriate recommendations for prevention. Through the identification of trends, risk factors and patterns that emerge through the review process, the MPDRC will generate recommendations for effective intervention and prevention strategies. This includes the promotion of research and the development of educational and policy initiatives focusing on the care provided to pregnant and post-partum women and their newborns.
Summary of 2016 Case Reviews
|EX-01||Maternal Executive||This case involved the homicide of a 29-year-old woman by her husband. At the time of her death, the woman was 20 weeks pregnant. Cause of death was drowning. Manner of death was homicide.||-||None|
|EX-02||Maternal Executive||The decedent was a 25-year-old G5P3A1.. The woman died while in the bathtub. Potential causes for the drowning include pregnancy-induced hypertension related seizure, cardiac arrhythmia or a fall in the tub.||-||None|
|EX-03||Maternal Executive||The decedent was a 35-year-old woman who died of gestational hypertriglyceridemia induced necrotizing pancreatitis.||-||None|
|EX-04||Maternal Executive||The decedent was a 42-year-old woman who died nine days postpartum following delivery of her fifth child. Cause of death was postpartum dissection of the left anterior descending coronary artery.||-||None|
|EX-05||Maternal Executive||The decedent was a 30-year-old G2P2 with a 4-year-old child and one-month-old infant . Cause of death was multiple organ failure due to a) sepsis and b) Strep A infection.||-||None|
|EX-06||Maternal Executive||The decedent was a 25-year-old with a past history that included three prior pregnancies, an appendectomy and mild illicit drug use. Her psycho-social history included domestic assault, depression and suicidal ideation. The cause of death was attributed to acute ischemic stroke, associated with pregnancy.||-||None|
|EX-07||Maternal Executive||This case involved the homicide of a 33-year-old woman by her husband who subsequently committed suicide. Cause of death was multiple blunt impact trauma in a woman with multiple stab wounds.||None|
|EX-08||Maternal Executive||The decedent was a 28-year-old woman with a past medical history that included left leg amputation below the knee due to complications of club foot for which she underwent multiple surgeries. Ehlers-Danlos syndrome type IV was diagnosed leading to uterine rupture and haemorrhagic shock.||-||None|
|EX-09||Maternal Executive||The decedent was a 31-year-old woman who died from ruptured ectopic pregnancy. The decedent was not aware that she was pregnant.||-||None|
|M-01||Maternal||The decedent was a 22-year-old G2P0A1 . Her past medical history was significant for cystic fibrosis (CF). Cause of death was pulmonary hemorrhage, complicating cystic fibrosis in a third trimester pregnancy.||-||None|
|M-02||Maternal||The decedent was a 34-year-old G2P0A1 . The cause of death was hypertensive heart disease which can result in sudden death due to cardiac arrhythmia.||-||None|
|M-03||Maternal||The decedent was a 37-year-old G5T2A2 . Cause of death was attributed to complications of Group A streptococcus sepsis.||-||None|
|M-04||Maternal||The decedent was a 23-year-old G3P0 . Cause of death was Group A Streptococcus (GAS) sepsis.||Diagnosis and testing||
|N-01||Neonatal||The deceased infant was two days old. The autopsy found a cephalohematoma and moderately severe subarachnoid hemorrhage. There was global and severe anoxic-ischemic encephalopathy. There was hemorrhagic necrosis of both adrenal glands related to trauma of delivery and/or perinatal hypoxia. No evidence of infection was found.||Education/Training
Policy and Procedure
Policy and Procedure Communications/documentation
Policy and Procedure
Communication/documentation Policy/Procedure Education/Training Resources
|N-02||Neonatal||The decedent was a 17.5-hour-old infant. The cause of death was severe hypoxic ischemic encephalopathy.||Policy and Procedures Communications/documentation||
|N-03||Neonatal||The deceased infant was two days old. Death was attributed to disseminated gram-negative Escherichia coli infection with meningitis due to, or as a consequence of, chorioamnionitis due to, or as a consequence of, preterm premature rupture of the membranes.||Policy and Procedures Communications / documentation||
|N-04||Neonatal||The deceased infant was two days old. Death was attributed to traumatic brain injury and hypoxic-ischemic encephalopathy arising as a complication of birth.||Policy and Procedures
Medical Education/Training Communications/documentation
|N-05||Neonatal||The deceased infant was 10 minutes old..||Diagnosis and testing - EFM Policy and procedure Transfer||
|N-06||Neonatal||The deceased infant was six hours old. The cause of death was intrauterine asphyxia.||Medical
Policy and Procedures
|N-07||Neonatal||The deceased infant was 24 hours old. The cause of death was hypoxic-ischemic encephalopathy as a complication of perinatal asphyxia.||Communications/documentation Policy and Procedures
|N-08||Neonatal||The deceased infant was one hour old. The cause of death was attributed to intrauterine aspiration pneumonia, due to chorioamnionitis, due to prolonged premature rupture of membranes.||None.|
|N-09||Neonatal||The deceased infant was one month old. The cause of death was total anomalous Pulmonary Venous Circulation with Right Ventricular Hypertrophy||Diagnosis and testing Communications/documentation Policy and procedure Communications/documentation||
|N-10||Neonatal||The deceased infant was 20 days old. The autopsy was restricted to the heart only. Cause of death was a congenital heart disease.||Diagnosis and testing Education/Training Communications/documentation||
|S-01||Stillbirth||This stillborn died from Acute Amniotic Infection Syndrome||Diagnosis and testing - EFM Communications/documentation||
|S-02||Stillbirth||Death was attributed to multiple placental factors in the setting of labour. These included placental hypoplasia with infarcts as well as chorioamnionitis (not of a degree to be the primary cause).||-||None.|
|S-03||Stillbirth||The cause of death was determined to be Morganella morganii bacteremia.||Policy and procedure Communications/documentation Quality||
Questions and comments regarding this report may be directed to:
Maternal and Perinatal Death Review Committee
Office of the Chief Coroner
25 Morton Shulman Avenue