Poor Reporting: Another Failure of the Canadian Healthcare Scheme

But ... the American system!:

A review of a decade of Ontario coroner’s reports shows the same observations cropping up again and again. Medical practitioners aren’t sharing vital information; patients aren’t being adequately monitored; and strained resources are undermining life-saving care. These circumstances can set the stage for tragedy.

(Sidebar: typical Canada. Protect the fiefdoms at all costs.) 

Between 2012 and 2022 alone, Ontario’s Office of the Chief Coroner’s Obstetric and Perinatal Death Review Committee made 458 recommendations, detailing a range of medical mishaps and missed opportunities behind 50 maternal deaths, 85 neonatal deaths and 25 stillbirths during that period.

And reporting of such repeated problems goes back even further. …

The IJB identified 17 coroner’s recommendations relating to hemorrhages in the decade ending in 2022. At least five recommendations arising from deaths in 2021 and 2022 called for standardized procedures in dealing with births involving excess bleeding.

But the problem goes back much further. For instance, 30 years ago, in 1996, an Ontario woman bled to death after giving birth, with deep lacerations in her vagina. The coroner’s jury examining her death made note of the need for timely intervention and “timely identification of estimates of blood loss.”

In 2010, an Ontario woman bled to death after giving birth. The coroner’s committee reminded care providers of the importance of assessing blood loss from postpartum hemorrhage.

In 2014, an Ontario woman bled to death giving birth after years of trying to conceive.

“Care providers poorly estimate blood loss and consistently underestimate the loss of a large volume of blood,” the coroner’s committee noted in response to her death.

The women’s home communities were not included in the reports.

Over a 20-year period from 2002 to 2022, 46 Ontario women bled to death after childbirth, comprising 27 per cent of pregnancy-related deaths during that period, according to a study published last year in the Journal of Obstetrics and Gynaecology of Canada.

Problems may arise from a failure to follow practices that have been shown to work, McMaster University obstetrician and researcher Rohan D’Souza said, or there may be a delay in diagnosis. And sometimes people go into childbirth in less than ideal circumstances: for instance, maybe their hemoglobin or iron levels are not optimal.

“Postpartum hemorrhage in itself is not always preventable … but death and serious complications from postpartum hemorrhage are always preventable,” D’Souza said.

**

The IJB found Canadian women are dying preventable pregnancy-related deaths and experiencing other adverse effects in childbirth. And Canada is bad at tracking maternal deaths. In fact, while data show a doubling in the maternal mortality rate for the decade ending in 2024, many experts think that reflects improvements in record-keeping rather than a dramatic rise in deaths.

Deaths during pregnancy, childbirth or following childbirth remain rare, but the IJB investigation shows health providers are missing opportunities to improve childbirth outcomes.

Canada is behind high-income European countries in tackling the “big three” leading causes of maternal morbidity and mortality: post-partum hemorrhage, hypertension and sepsis, says McMaster University obstetrician and researcher Rohan D’Souza.

“The deaths from these causes are completely preventable,” he says. “It’s about access. It’s about equity.” ...

 

(Sidebar: equity? As in other people are dying of blood loss?)

We do not have an ability in Canada to learn the lessons of our errors in a systemic, national way.

Damn right.

Because Canada.