HOME >Special Edition: June 2008 Joint Conference - Volume 52 - Number 3

Paediatric Death Review Committee 2008 Annual Report
Coroner recommends public education on safe sleeping for infants and children
By Marie-Lauren Gregoire, OACAS Communications Coordinator


Click here to download this report.Dr. Bert Lauwers and Karen Bridgman-Acker presented the report of the Paediatric Death Review Committee (PDRC) to child welfare professionals on the last day of the conference.

The Associate Deputy Coroner indicated the most common causes of child deaths are natural, however, other causes include accident, homicide and undetermined.

One of the main causes of child deaths is unsafe sleeping environments. Unsafe sleeping practices include:

  • Adult beds used at home or for napping when visiting relatives or friends
  • Bed sharing or co-sleeping - room sharing is encouraged
  • Couches and sofas should not be used as sleep surfaces for babies
  • Crowded cribs are dangerous – keep cribs clear of toys, pillows, blankets, stuffed animals, and bumper pads
  • The safest sleeping environment for an infant is on its back in an empty crib with a firm mattress

The PDRC, a multidisciplinary committee of the Office of the Chief Coroner of Ontario, reviews all child deaths in Ontario including those child deaths where a child welfare agency has had some involvement with the child and/or family within the previous year. In 2007, the Paediatric Death Review Committee examined the circumstances surrounding the deaths of 91 children between the ages of 0 and 18 years. The Deaths Under Five Committee reviewed 117 deaths. The presentation focused on the issues and themes raised in 35 cases reviewed by the PDRC in 2007 where a Children’s Aid Society (CAS) was involved with the family during the preceding 12 months.

The purpose of review is to analyze the circumstances of the death, the services provided to the family, and to make recommendations for possible prevention of future deaths under similar circumstances. The recommendations are focused on promoting best practices within the child welfare and medical systems and educating the public on child safety measures. The Annual Report produced by the PDRC summarizes the findings, statistics, recommendations, trends and themes identified in these reviews.

The main recommendation of this report is increased public education about safe sleeping practices. CASs educate parents about safe sleeping practices and ensure child protection workers complete safety assessments of the child’s home, especially the sleeping areas for infants. Ontario’s CASs need the support of community partners and professionals to educate parents about safe sleeping practices, positive parenting and the duty to report.

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