Death Investigations

All deaths that are unnatural, unexpected, unexplained or unattended must be reported to a coroner. Upon receiving a report of a death, the coroner begins an investigation, which proceeds in one of three ways: Natural Death, Coroner's Investigation or Coroner's Inquest.

Natural Death

If, after reviewing the circumstances of death and speaking with the personal physician, the coroner determines that the death was due to a natural causes, the coroner will contact the personal physician of the deceased to obtain information on medical history.

If it is confirmed that the death is natural, the responsibility for completing the medical death certificate remains with the physician, and no further investigation from the Coroners Service is required. See Section 15 of the Coroners Act for more information.

In cases where an autopsy is not required for the coroner’s investigation, families seeking information about clinical autopsies should speak with their medical practitioner.

Coroner's Investigation

An investigation is conducted and a coroner’s report is written. When a death is reported to the coroner, he/she has the authority to collect information, conduct interviews, inspect and seize documents and secure the scene.

Upon conclusion, the facts as determined by the investigation are released in a report. It sets out the coroner’s findings, including a cause of death and whenever possible, recommendations to prevent future deaths.

To request a copy of a coroner's report, please click here.

Autopsy

The Coroners Act gives a coroner the authority to investigate the facts and circumstances of a death, including:

• taking possession of a body,
• examining a body, and
• authorizing a medical practitioner or any other qualified person to do any examination or analysis the coroner considers necessary, including an autopsy and analysis of substances in the body.

For homicides or suspicious deaths autopsies are mandatory and police agencies take the lead on communication with the primary contact (nearest relative/personal representative).

In all other cases, the coroner will discuss autopsy requirements with the primary contact and explain why an autopsy is or is not being considered. This is to ensure all questions and concerns are thoroughly addressed, with the goal of ensuring culturally safe services and meeting the needs of families. The coroner has the authority to proceed with an autopsy or other analysis when required whether or not the primary contact is opposed to it.

Coroner's Inquests

Inquests are formal court proceedings, with a five-person jury, held to publicly review the circumstances of a death. The jury hears evidence from witnesses under subpoena in order to determine the facts of the death. The presiding coroner is responsible to ensure the jury maintains the goal of fact finding, not fault finding. Once an inquest is held, a Verdict at Inquest is written. See the Coroner's Inquests page for more information.

Recommendations

When appropriate, the Coroners Service delivers recommendations aimed at preventing future deaths in similar circumstances. The agency maintains a database and conducts regular surveillance of common causes and circumstances of death in order to identify public health and safety risks and trends. When such issues are identified, the agency may conduct additional reviews and studies aimed at establishing effective and practical prevention measures.