Ministry of the
Solicitor General

About death investigations in Ontario

Death Investigations in Ontario

About Death Investigations in Ontario

In Ontario, death investigation services are provided by the Office of the Chief Coroner and the Ontario Forensic Pathology Service.

The Office of the Chief Coroner works closely with the Ontario Forensic Pathology Service to ensure a coordinated and collaborative approach to death investigation in the public interest. Together, the Chief Coroner and Chief Forensic Pathologist provide dual leadership for Ontario’s death investigation system that strives to provide services of the highest calibre.

The Office of the Chief Coroner serves the living through high quality death investigations and inquests to ensure that no death is overlooked, concealed or ignored. The findings are used to generate recommendations to help improve public safety and prevent further deaths.

In Ontario, coroners are medical doctors with specialized training in the principles of death investigation. Coroners investigate approximately 17,000 deaths per year in accordance with section 10 of the Coroners Act.

The Ontario Forensic Pathology Service provides forensic pathology services in accordance with the Coroners Act. It provides medicolegal autopsy services for public death investigations under the legal authority of a coroner. The Ontario Forensic Pathology Service performs over 7,500 autopsies per year.

Child and Youth Death Review: Pilot Project Notice

Since 1991, the Office of the Chief Coroner has been conducting reviews of child and youth deaths (0-19 years) in Ontario for the purpose of identifying risk factors and recommendations to prevent premature death. The Paediatric Death Review Committee has conducted thousands of case reviews since its inception in keeping with the public safety mandate of the Office of the Chief Coroner.

As part of the plan to improve the health, safety and well-being of Ontario children and youth, the Office of the Chief Coroner is working to update and expand its current approach to child and youth death review. In 2014, a partnership was formed with the Ministry of Children, Community and Social Services and the former Ontario Child Advocate to develop a best in-class model of child and youth death review and analysis. The objective of the new model will be to improve the health, safety and well-being of Ontario’s children and youth and reduce the child and youth mortality rate in Ontario.

The Office of the Chief Coroner has launched a pilot project that will collect and link data on all deaths of children and youth to better understand how life circumstances can influence the deaths of young people in Ontario. The Child and Youth Death Review and Analysis (CYDRA) Data Integration Pilot Project will be collecting personal data from five public sector ministries on young people between the ages of 10 to 24 (inclusive) who have died between 2007 and 2018 as part of a coroner’s investigation into deaths of children and youth in Ontario.

The data will be linked together to inform the creation of a risk predictive model. This model will help us learn more about the life trajectories of specific young people who have died by suicide and gun-related homicide.  We also expect to evaluate trends on these particular death types that can then be used to support the research and development of effective strategies to prevent further deaths, in the interest of public health and safety.

Personal information being collected will be done so under the authority of the Coroners Act, R.S.O. 1990 C. C. 37 as amended, the Freedom of Information and Protection of Privacy Act and the Youth Criminal Justice Act. Question about this collection and this project should be directed to:
Chief Coroner
25 Morton Shulman Avenue
Toronto Ontario M3M 0B1
tel: 416-314-4000 or toll-free: 1-877-991-9959
or by email at:

NOTE: The CYDRA team within the Office of the Chief Coroner is a project based team that will be leading this pilot project as part of its mandate to review and analyze deaths of young people in Ontario. The CYDRA team was created to support the development and implementation of this pilot project by testing the concepts and structure of a "best-in-class" model of child and youth death review and analysis in Ontario.