Good morning, Madam Chair and members. I'm here representing Dr. Bonita Porter, the Chief Coroner for Ontario, who unfortunately couldn't be here and sends her regrets.
What I'd like to do this morning is give the members a brief overview of death investigation in Canada and in Ontario in particular—which is what I know best—speak about our role in adverse drug event reporting, and perhaps offer some suggestions to the committee for their consideration.
In Canada we have a mixture of death investigation systems. We have medical coroners, as in Ontario; lay coroners, as in provinces like British Columbia; and medical examiner systems, as in Newfoundland, Alberta, and others. Dr. Haggie represents one such system. In the Northwest Territories, Nunavut, and the Yukon, there are lay coroners. That's simply related to the lack of resources and people in those areas, and the vast distances.
All coroners and medical examiner systems, however, have the same goal in mind. There are mandatory questions that must be answered about deaths that are investigated, there is a need to support the criminal justice system, and finally, there is the goal of advancing public safety.
In our office in Ontario we investigate about 20,000 of the 80,000 or so deaths that occur per annum in the province. Those investigations are conducted by approximately 300 coroners, all of whom are practising physicians in Ontario and all of whom have full-time jobs doing something else, except for people like me; I represent one of the nine regional coroners who report to the chief coroner for the province.
Of the 20,000 deaths we investigate per annum, approximately 15,000 are determined to be natural, and it is in that category of death that we find most of the adverse drug events. Over the years we have not had, in my view, the majority of cases reported, and I think this parallels reporting in other jurisdictions and other systems. A variety of factors relate to that, many of them common to the difficulties faced by physicians in practice in general.
For your information, over the last five years there were 176 adverse events reported that were associated with death but did not directly cause the death. Those are “involvements”, or what we term to be “significant contributors”, but not the actual cause of death. Over those five years we had 18 cases reported in which it was felt that the adverse drug reaction itself caused the death. My strong suspicion is that this number under-represents the total significantly. I think the committee should be aware of that, and it does speak to the need to enhance the reporting mechanisms available in Canada to report these kinds of events.
In our work as coroners we make liaison with organizations such as yours, obviously, in the Parliament of Canada, and also with ministries in Ontario, such as the Ministry of Health and Long-Term Care and the Ministry of Labour. We've recently had dialogue with Health Canada and had a visit from Ms. Pepper, who represented the Canada Vigilance program and spoke to us about the need for us to liaise with them. We certainly support that need and initiative and want to increase and enhance our involvement with Health Canada in this regard.
Since 2001 there has been a formal request directed at coroners on behalf of the chief coroner to ensure that adverse drug events are reported. We have recently revamped our investigation information system, which is comprehensive and computer based, to allow us to capture more accurately the type of drug adverse reaction that has occurred, so now we capture the adverse drug reaction, which we define as a “noxious or unintended response to a drug that is used at therapeutic, prophylactic or diagnostic doses” and “directly leads to death”. That's a situation in which we would call it the death factor or the prime cause of death.
We also track, however, what are termed as “involvements”. An involvement, to us, is a serious adverse drug event that contributes to the death, but doesn't cause it directly. This is our definition; it differs from the Health Canada definition. Perhaps it is most germane to think of those as the iceberg and the small number of cases in which death actually occurs as the tip. Nonetheless, both are very important.
We do a number of things in response to situations in which an adverse drug reaction has caused a death. We may call an inquest. An inquest in Ontario is a relatively uncommon event now, for a variety of reasons. There used to be hundreds; there are now perhaps 50 to 70 per year, and of those the vast majority are mandatory.
We may call what's called a regional coroners review, which is a formal review in a committee-like setting with the health care provider or institution to discuss the event that occurred and hopefully generate findings and recommendations aimed at the common goal of advancing public safety and preventing a similar death in the future.
We may refer the case to one of our expert committees, and one of those committees is the patient safety review committee, which I chair. That committee is comprised of a multidisciplinary group. The Institute for Safe Medication Practices is represented by Mr. David U. There are various specialists in medicine, nursing, systems safety, and we will review cases in a paper manner and produce a report, which is then distributed to the concerned parties, including the providers and, of course, the next of kin.
That information is often disseminated through other media—one such example would be the Dialogue of the College of Physicians and Surgeons of Ontario, or the Canadian Medical Association Journal, and so on—to try to increase the knowledge of practitioners and people who ought to be aware of the problem.
We find at that committee that about a third of the cases we see have some involvement with medication. It is a very prevalent and prominent issue for us, and we think it is for you as well.
I would just say in closing that we are most prepared to participate in reporting and liaison with Health Canada to try to advance the common goal of improving the safety of the public in Canada.