Identifying when, why and how to analyze and learn from deaths in healthcare settings
Publication year: 2015
Each year more than 1,000 children and youth (0-19
years of age) die in Ontario.(1) The Office of the Chief
Coroner has consistently investigated between 43-49%
of these deaths each year,(1) and many of these
investigations offer opportunities to learn from the
circumstances of the death, although the extent to which
these deaths are the result of modifiable factors (i.e.
preventable) is currently unknown. The Office of the
Chief Coroner of Ontario (OCC), which requested this
rapid synthesis, has significant experience in undertaking
death reviews – approximately 15% of the deaths of
children and youth in Ontario are subject to review by
an expert death committee of the OCC, in addition to
adult deaths which are also reviewed in certain
circumstances. The OCC is evaluating the current
approach to reviewing the deaths of children and youth,
with the objective of providing high quality death
reviews to promote and advance death prevention. The
OCC is interested in the experiences of the healthcare
system, including hospitals, to inform an approach to
analyzing and learning from these deaths. Specifically,
the OCC was interested in the circumstances under
which hospitals and other care providers conduct
reviews of deaths, the criteria used for selection of
occurrences, the objectives of reviews, the process
undertaken, and the ways in which data, information and
recommendations are collected and used.