NOTE: This is general information and must not be interpreted as a legal description of the Coroner’s role or the Coroner’s Inquest. Reference should be made to the Coroners Act for complete information.
Ontario is a diverse province, and the Coroners’ Office respects the many different religious and philosophical views of Ontarians concerning death. We aim is to keep you informed during the investigation, to answer questions, and to take into account beliefs, bearing in mind the importance of a complete and accurate death investigation.
This information is meant to help you understand the process of death investigation in the Province of Ontario. In the spirit of respecting diversity the Coroners’ Office is pleased to offer individuals whose first language is not English translation services via telephone in the language of their choice. Please enquire through the investigating coroner for access to this service.
Who is a coroner and what is the coroner’s job?
Coroners in Ontario are medical doctors with specialized training in death investigations. Coroners are available to the community 24 hours a day, seven days a week.
Coroners report to the Chief Coroner who is responsible for all coroners in Ontario. Coroners investigate deaths that happen under certain circumstances as determined by a provincial law called the Coroners Act of Ontario.
What is a death investigation?
A death investigation assists the coroner to understand how and why a person died. This information may help prevent other deaths in similar circumstances. A death investigation is sometimes referred to as a coroner’s case.
Coroners must answer 5 questions when they are investigating a death:
The coroner learns this information from many different sources including: family, neighbours, doctors, hospital records and police.
How are the police involved in a death investigation?
Police usually respond to all emergency calls and are often the first ones at the scene of a death.
The Coroners Act states that police may be called upon to help coroners conduct their investigations.
Why is a coroner called? What is a reportable death?
Coroners are called to investigate deaths that appear to be from non-natural causes. They also look into some natural deaths, such as those that happen suddenly and unexpectedly. Coroners may be involved when people have concerns about the care provided before death.
Coroners are also called for all deaths of people in custody, for many deaths in long-term care facilities, and if the death happens on a work site.
These types of deaths are also referred to as reportable deaths, because they must be reported to a coroner.
Who calls the coroner?
Anyone who thinks that a reportable death has happened must call a coroner right away. This usually means a health care professional or the police, but it can be any member of the public, including a family member.
What is an autopsy?
An autopsy is performed in many death investigations, but not all of them. An autopsy is a way of looking very closely at the inside of a person’s body after the person has died. It is also called a post-mortem examination.
An autopsy includes looking at organs and tissues from the body and looking at small tissue samples under a microscope. It may also include testing for drugs, chemicals, poisons, or infections.
Who decides if an autopsy is done?
What if I have concerns?
The coroner will decide if an autopsy is needed, sometimes in consultation with a pathologist. The coroner will explain the need for an autopsy and will listen to any concerns or objections brought forward. While individual views will be carefully considered, it is important to understand that the coroner’s decision for autopsy is final and legally binding. This means that the law allows the coroner to go ahead with the autopsy if the coroner feels this is necessary for the investigation.
In doing so, coroners are expected to seek input from families as they often have important and relevant information to aid the investigation.
Who performs the autopsy?
The coroner directs a pathologist to perform the autopsy. A pathologist is a medical doctor with specialty training in examining body tissues to look for signs of disease, injury, or other changes.
In certain cases, a forensic pathologist may perform the autopsy. A forensic pathologist has further specialty training in determining causes of death. Forensic pathologists work in special Forensic Pathology Units throughout the province.
Will the death investigation affect my plans for a funeral or service?
In some cases, the funeral or other services may be delayed by the autopsy or other aspects of the death investigation.
Religious or spiritual practices may dictate certain time frames. If this is the case the coroner should be informed and if at all possible efforts will be made to complete the examination within the required time frame.
What happens to the body?
In most cases, the family members make arrangements to have the body transported to the funeral home from the place of death. However, in some cases it will be necessary for the coroner to have the body transported to hospital or Forensic Pathology Unit for further testing such as an autopsy.
Sometimes in rare circumstances and depending on the type of death, organs (usually brain or heart) may need to be kept after the autopsy to perform further testing to help answer the questions of the coroner.
Can organs be kept as part of the autopsy?
Retaining organs is sometimes necessary in order to determine cause of death. If necessary, the Coroner will inform if an organ(s)) will be kept. This is a coroners’ decision as stated in the Coroners Act of Ontario. The coroner will ask what is to be done with the body’s organs after the testing is done. (The organ(s) can be returned to the funeral home or can be cremated by the Office of the Chief Coroner).
It is common practice for the pathologist to keep small samples of tissues for ongoing study in helping to answer the facts around the death.
Can organs/tissues be donated after death?
If organ and/or tissue donation is a consideration, consent must be given. In Coroner’s cases the consent can be given by a family member. The coroner must be informed of these wishes and will advise if it is possible to meet this type of request.
What is an inquest?
What happens during an inquest?
Some types of deaths lead to a mandatory inquest under the Coroners Act.
A coroner may call an inquest. A family member may in writing also request an inquest. The Chief Coroner makes the final decision as to whether one will be held.
Inquests are held for several reasons that might include:
An inquest is a process of asking questions and getting answers that is supposed to help focus public attention on the facts of the death.
An inquest is led by a coroner with a jury of five people. It is the job of the jury to hear the evidence, answer the five questions and if possible, make recommendations to prevent deaths in similar circumstances. Juries cannot find fault or assign blame and their recommendations are not legally binding.
Inquests are open to the public and may be reported by media. Family members can attend but do not have to unless called as a witness.
Families may apply to participate in the process, and they may be represented by legal counsel, themselves or certain other persons approved by the Law Society of Upper Canada.
I still have questions. What do I do?
Write down the names and telephone numbers of the suggested contact people listed below. If you are not given these numbers, please ask the coroner.
If you do not have this contact information, you can contact the Office of the Chief Coroner to ask for help.
If English is not your first language, please ask the coroner if there are services and/or information available in your language of choice.
How do family members obtain information/reports?
Results of a death investigation can be shared with immediate family members (spouse, child, sibling, parent) or a personal representative when an investigation is finished. Family members need to make their request in writing to the applicable regional office listed below. The following information is required:
Name of the deceased
Date of death (if known)
Relationship to the deceased
Family member’s signature.
For your convenience, a form is provided (PDF, 66.1 kb) that can be easily printed and completed. If you require more information, please contact the applicable regional office.
When can family members reasonably expect to receive the reports?
The length of time it takes to conclude a death investigation depends on the number and types of tests that may be required, as well as the volume of information that may need to be reviewed. While there is no definitive time frame, as every death investigation is unique, families can expect to receive some information within six to nine months after the death. In complex cases, the final opinion of the Office of the Chief Coroner and actual reports may take significantly more time. Family members can be updated by contacting the investigating coroner or the regional office.
A family member is having difficulty reaching the investigating coroner. Is there someone else who can assist them?
In addition to the investigating coroner, family members may contact the regional office for updated information. Contact information can be provided by the investigating coroner, on the ministry’s website or by calling 416-314-4100 or toll-free at 1-877-991-9959.
How to get a death certificate?
The coroner creates an original copy of the Medical Certificate of Death and sends it to the office of the Registrar General. Only the Registrar General can issue a copy of the death certificate.
Here is the online contact and telephone number:
Toll Free: 1-800-461-2156 - (Ontario only)
Tel: (416) 325-8305
Fax: (807) 343-7459
Business hours: 8:30a.m. – 5:00 p.m. Monday - Friday
What about other forms that might be needed?
Other forms may be needed to claim for benefits as a result of a person’s death. Please check with the insurance company. Funeral homes often will be able to inform what forms are needed. Sometimes the coroner needs to complete these forms. If so, please contact them.
Brampton Office: Tel: 905.874.3972 Fax: 905.874.3976
24 Queen Street East, Ste 700, Brampton ON L6V 1A3
Boundaries: Durham, Muskoka, York
Guelph Office: Tel: 519.837.6330 Fax: 519.837-6329
1 Stone Road West, 1st Floor, Guelph ON N1G 4Y2
Boundaries: Halton, Peel, Simcoe, Wellington
Toronto East (east of Yonge St.) Tel: 416.314.1013 Fax: 416.314.4030
26 Grenville Street, Toronto ON M7A 2G9
Toronto West (west of Yonge St.) Tel: 416.314.4105 Fax: 416.314.4030
26 Grenville Street, Toronto ON M7A 2G9
Kingston Office: Tel: 613.544.1596 Fax: 613.544.3473
366 King Street East, Ste. 440, Kingston ON K7K 6Y3
Boundaries: Dundas, Frontenac, Glengarry,
Grenville, Lanark and Leeds, Ottawa,
Prescott, Russell, Stormont, Prince Edward,
Stormont Lennox and Addington
Peterborough Office: Tel: 705.755.5265 Fax: 705.755-5266
270 George Street North, 1st Floor, Box “D”, Peterborough ON K9J 3H1
Boundaries: Kawartha Lakes, Haliburton,
London Office: Tel: 519.661.6624 Fax: 519.661.6617
235 North Centre Rd., Ste. 303, London ON N5X 4E7
Boundaries: Bruce, Chatham-Kent,
Elgin, Essex, Grey, Huron,
Lambton, Middlesex, Perth, Oxford
Hamilton Office: Tel: 905.546.8200 Fax: 905.546.8210
119 King Street West, 13th Floor, Hamilton ON L8P 4Y7
Boundaries: Brant, Dufferin, Haldimand,
Hamilton, Niagara Norfolk,
Thunder Bay Office: Tel: 807.343.7663 Fax: 807.343.7665
189 Red River Road, 4th Floor, PO Box 4500, Thunder Bay ON P7B 6G9
Boundaries: Algoma, Cochrane, Kenora,
Rainy River, Thunder Bay
Sudbury Office: Tel: 705-564-6149 Fax: 705-564-6155
199 Larch Street, 2nd Floor, Sudbury ON P3E 5P9
Boundaries: Parry Sound, Manitoulin, Nipissing, Sudbury, Timiskaming, Algoma, Cochrane