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.