Speaking for the Dead: Ontario’s Death Investigators

Office of the Chief Coroner

Office of the Chief Coroner

Ontario plans to expand the role of forensic pathologists, strengthen the inquest process and broaden the role of the Death Investigation Oversight Council (DIOC).

The changes were announced Aug. 7 by the Minister of Community Safety and Correctional Service. They follow a comprehensive review of Ontario’s death investigation system, done by KPMG for the Chief Coroner and Chief Forensic Pathologist, organizations that provide death investigation services in Ontario.

One large piece of the change has caused some push-back from the province’s coroners: appointing forensic pathologists as coroners.

It is expected that forensic pathologists appointed as coroners will conduct “end-to-end” death investigations in approximately 250 death investigation cases each year, or approximately 1.6 per cent of all cases. The new model will be reviewed after two years.

Dr. Dirk Huyer, Interim Chief Coroner for Ontario, said the measures “support our continued evolution as a high-quality death investigation system, in which coroners and forensic pathologists collaborate and play complementary roles in protecting and improving public safety.”

Investigating Deaths

Ontario is a leader in death investigation; the DIOC is unique. It provides independent oversight of Ontario’s coroners and forensic pathologists by ensuring that death investigation services are effective and accountable.

Coroners in Ontario are medical doctors with specialized training in death investigations. Coroners are available 24 hours a day, seven days a week and report to the Chief Coroner.

The Office of the Chief Coroner investigates approximately 16,000 deaths per year across Ontario. Currently, approximately 6,000 of these cases require an autopsy, performed by a forensic pathologist.

Coroners must answer five questions when investigating a death:

  • Who was the person? (identification)
  • When did they die? (the date of death)
  • Where did they die?
  • How did they die? (the medical cause of death)
  • By what means did they die? (the category of death; this can be either natural causes, accident, homicide, suicide, or undetermined)

Coroner’s work is a low-profile area that has deep and long-lasting effects on public health and welfare, jurisprudence and other aspects of the paralegal scope of practice. Coroners’ jury recommendations have affected product packaging, led to recalls, changed police protocols, affected the way jury rolls are created in Ontario, and resulted in changes to health and safety regulations.

The Office of the Chief Coroner for Ontario says that it “speaks for the dead, to protect the living” by providing high-quality death investigations and inquests, ensuring that “no death will be overlooked, concealed or ignored.”

Worst-case Scenario Prevention

Ontario’s Office of the Chief Coroner conducts 16,000 forensic death investigations each year, including inquests into workplace and in-custody deaths. It is responsible for storing human remains, signing cremation certificates and out-of-province shipments, inspecting Schools of Anatomy in Ontario, managing the provincial Multiple Fatality Plan, and supervising and educating investigating coroners and pathologists across the province.

Forensic examinations are performed in cases involving injury or death in unusual circumstances, and in crimes against persons or property.

The Ontario government is implementing recommendations in a report by former Supreme Court of Canada Justice Frank Iacobucci. The Iacobucci Report Implementation Committee met in Toronto, in June.

A coroner’s inquest into the deaths of Native students in Northern Ontario brought the issue of jury rolls into focus and led to the Iacobucci Report. Inquest-related decisions have also affected jury trials in the province, of both Native and non-Native defendants.


    More Information

    New Forensics Centre Built in Downsview

    Read the Coroners Act

    Death Investigation Oversight Council


    Related Cases:

    R. v. Omstead, 1998 CanLII 14771 (ON SC)
    Outlines the purpose and principles of an inquest.

    Connolly v. Coroner, 2013 ONSC 2874 (CanLII)
    Judicial review, mandamus application for an inquest.

    Pierre v. McRae, 2011 ONCA 187 (CanLII)
    Jury-roll issue delays inquest; case cited in non-inquest matters.


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