PRACTICE PARTNER
The following recommendations have been compiled from the reports of the expert review
committees of the Office of the Chief Coroner, patient safety organizations, and inquests.
Contact coroner when relatives concerned
about care provided to deceased relative
T
he Chief Coroner’s Maternal
and Perinatal Death Review
Committee reminds physicians to
contact the Coroner’s Office when
family members appear to have
concerns about the care that has
been provided to their deceased
relative.
The reminder stems from a case
involving an infant born at 25
weeks and 6 days gestation, who
died in the neonatal intensive
care unit. The child had a complicated course requiring NICU
care including respiratory support,
expressed breast milk with breast
milk fortifiers, and red blood cell
transfusion. Unfortunately the
child developed and succumbed to
necrotizing enterocolitis (NEC).
The Committee generally found
that the care was acceptable but
did note that the parents had
expressed a number of concerns
during the course of the child’s
illness. The care providers had not
contacted the Coroner’s Office.
In this case, it was the family that
contacted the Coroner’s Office.
“It would have been warranted
and helpful if the members of the
clinical team at the tertiary neonatal centre and the hospital had
informed the coroner of the baby’s
death,” wrote the Committee in
its rep ܝ