Death Investigations - Strategic Plan 2015-2020
Strategic Plan for Ontario’s Death Investigation System,
From the Deputy Minister of Community Safety
As part of the Ministry of Community Safety and Correctional Services, the organizations that form Ontario’s death investigation system serve a fundamental and unique role to strengthen public safety and security. Our collective goal is to ensure that public safety systems are safe, secure, effective, efficient, accountable and responsive to the needs of all of Ontario’s diverse communities. We are committed to Ontario families and aim to support them in their time of need.
By maintaining a united front with our partners, we are paving the road for success, through innovation and collaboration. Our valuable stakeholders are helping to steer the ship on the future of Ontario’s death investigation system. Through their engagement, we have learned that better communication and public education will prove to be beneficial and worthwhile.
I am confident that the strategic plan outlined here will set Ontario’s death investigation system on a course to deliver the highest quality public service over the next five years in support of both the government and ministry priorities.
I commend the staff and leadership of the organization for recognizing the sensitive and often personal interface the organization has with Ontario’s families and communities and the resulting emphasis that has been placed on responsive public service. We are eager to take the first steps in executing our unified strategy. As world leaders, this is an exciting time for Ontario’s death investigation system.
Simply put, this thoughtful plan and the strategic priorities identified within put the right people, in the right place doing the right things for the right reasons.
Deputy Minister of Community Safety
The strategic plan outlined here is a significant step towards ensuring high quality death investigation services for all Ontarians. This plan represents an important and exciting new phase of unity and collaboration between coronial and forensic pathology services in Ontario.
This plan was created with substantial public and stakeholder engagement. For the first time, direct feedback from families across Ontario was considered in the development of strategic priorities. The Council believes this feedback is critical to ensuring the system is responsive to the diverse needs of Ontarians.
The strong emphasis on regional service delivery and capacity within this plan means that, regardless of location, a family will receive the same high-quality death investigation services.
The need to deliver just outcomes cannot be overstated. Achieving this will mean taking all necessary and attainable steps to increase public information about, and understanding of, the death investigation system.
Consistent with our mandate, the Council members look forward to continuing to work with the Office of the Chief Coroner and the Ontario Forensic Pathology Service on the action plan to implement this strategic plan.
Hon. Joseph James
Chair of the Death Investigation Oversight Council
We are pleased to share our “Strategic Plan for Ontario’s Death Investigation System, 2015-2020.” This plan lays the foundation for our future direction and a framework to achieve our goals for the next five years. Moving forward, we will continue to build from past accomplishments and forge ahead through the commitment and passion of our people.
First and foremost, we are a public service. It is our responsibility to serve Ontario’s diverse people, families and communities during times of profound grief and loss. We aspire to improve the health and safety of Ontarians in three critical areas. Firstly, we support the needs of families by providing answers and information after sudden and unexpected deaths. Secondly, we search for the truth and provide evidence and data to support the administration of justice. Finally, through knowledge and capacity development, we advance forensic medicine and public safety. Ultimately, our combined activities support efforts to prevent future sudden and unexpected deaths.
We continue to grow and benefit from the integral partnerships developed to benefit community safety in the broader public sector as well as in the academic and medical communities. The strategic priorities presented reflect the experiences and feedback of our many stakeholders, professionals, and partners who work with and contribute to the death investigation system. Importantly, our priorities also reflect the direct experiences and feedback of the public and families we serve.
Our strategic plan is aspirational and ambitious. It articulates our focus on providing services that are modern, relevant and reflective of the evolving needs of Ontario’s diverse communities. We will concentrate our efforts and resources on areas where we have the greatest impact. Data will drive our decisions and we will seize opportunities for innovation and growth that will advance health and safety. We will continue to be a global leader in the development of death investigation and forensic pathology. Above all, we will be accountable and responsive to Ontarians.
We are embarking on a five-year journey to achieve the goals set out in this plan. By engaging in further dialogue, encouraging collaboration, and capitalizing on the talent and expertise of our people, we will produce the operational and business strategies that will achieve our objectives.
Our collective vision is a high-quality death investigation system for a safer and healthier Ontario. It is our hope that our vision, our plan, and our future actions resonate with all of those who participate in, or are impacted by, Ontario’s death investigation system.
Dirk Huyer, MD
Chief Coroner for Ontario
Michael S. Pollanen, MD, PhD, FRCPath, DMJ (Path), FRCPC Founder, forensic pathology
Chief Forensic Pathologist for Ontario
Director, Operational Services
The Government of Ontario has the responsibility of caring for its citizens from birth through to death. Our team is honoured to play a critical role in fulfilling this responsibility. We impact the lives of Ontarians through the unique nature of our mandate. The core of our work is the search for the truth. We seek to identify the cause and manner of reportable deaths and through this work, develop recommendations to improve public safety and health to benefit the people of Ontario.
Ontario’s death investigation system is involved in investigating approximately 15,000 deaths per year, including approximately 5,800 post mortem examinations and between 30 to 50 inquests, in accordance with the Coroners Act. For each death investigated under the Act, we must answer five questions: determining the identity of the deceased; how the death occurred; when the death occurred; where the death occurred; and by what means the death occurred. We then study the information obtained through our investigation and analysis with the intent of making recommendations aimed at preventing deaths in similar circumstances.
As the largest death investigation system in North America, we are uniquely positioned to create a meaningful impact that can improve the safety and health of Ontarians and establish ourselves as global leaders in death investigation.
The death investigation system provides a public service to the 13.7 million people of Ontario who live across the province’s more than one million square kilometres. Over 85% of this population lives in urban centres, and we recognize that needs vary greatly between our urban and rural service areas. Ontario’s population is projected to grow by 31.3%, to a total of approximately 17.8 million by 2041, which will place increased demands on our system. Ontario is the most culturally diverse population in Canada, with over one quarter of all residents born outside of the country. Annually, 100,000 immigrants move to Ontario, which represents almost half of all of Canada’s yearly immigrants. First Nations communities further contribute to our province’s diversity. In fact, Ontario is home to the greatest number of individuals of Aboriginal descent in all of Canada.
While the geography and population distribution of the province, coupled with the diversity of cultures, linguistic, religious and spiritual beliefs create logistical challenges, our organization has and will continue its commitment to delivering local/regional services where possible. We are keenly aware of the impact of our involvement in the very personal experience of death and loss, and we recognize the important support that local community resources can provide during these times.
Who We Are
Ontario’s death investigation system is delivered in partnership by the Office of the Chief Coroner (OCC) and the Ontario Forensic Pathology Service (OFPS) and supported by the Operational Services Branch (OSB). We receive oversight from the Death Investigation Oversight Council (DIOC), who provide advice on behalf of the public. Ontario’s death investigation system operates under the authority of the Ministry of Community Safety and Correctional Services (MCSCS). As such, our strategic plan is aligned with the broader ministry strategic framework and we are fully committed to upholding the ministry’s vision for a “safe, strong, secure Ontario.” We have ensured that our vision, mission, and strategic plan also align with the overarching government mandate and priorities.
Ontario’s death investigation system is equipped with incredibly talented team members who possess a diverse set of skills, knowledge and experience. Working collaboratively, we strive for continuous improvement and the highest level of quality in the interest of the public. The system currently relies on the capabilities, knowledge, and experience of a workforce of over 500 professionals, including approximately 120 full-time staff, 300 coroners, 100 registered pathologists and several other specialists who work on a fee-for-service basis.
Both the OCC and OFPS have a significant provincial footprint with regional centres of excellence supporting local service delivery. The OCC, OFPS and OSB are headquartered at the new state-of-the-art Forensic Services and Coroner’s Complex located in northwest Toronto and co-located with the province’s crime lab, the Centre of Forensic Sciences, and the Office of the Fire Marshal and Emergency Management. The complex includes two dedicated inquest courts, the Provincial Forensic Pathology Unit, our education centre and our level three Containment/Bio-safety morgue.
The province has been divided into 10 regions, each of which is serviced by a regional supervising coroner and six Regional Forensic Pathology Units (RFPU) affiliated with medical schools. In addition, perinatal and pediatric forensic centres of excellence are located at Mount Sinai Hospital, the Hospital for Sick Children, and the Children’s Hospital of Eastern Ontario. Additionally, 24 community hospitals across Ontario support the provision of pathology services on behalf of the OFPS. The division is excited to introduce the establishment of a new centre of excellence for forensic pathology in Sault Ste. Marie. This will add greatly needed forensic pathology capacity to service remote northern and First Nations communities.
Our Current Environment
In developing the strategic plan to provide a framework for the future, it was essential to fully consider the current environment. We took a balanced approach by considering both our experiences and the important views of partners, stakeholders, as well as families from across Ontario.
Through consultation and research, we identified many opportunities and challenges that influence the organization’s future strategic direction. The following features of our operating environment provide context as we consider our current state and future direction:
- The government is focused on meeting fiscal targets with an emphasis on investing in public services that are efficient, relevant and have measurable outcomes.
- We are subject to uncontrolled variables – new and emerging trends in preventable deaths (e.g., opioids, suicides, genetic disease), fluctuating case volumes and complexity, and a diverse population with changing demographics.
- The organizations have undergone tremendous growth and organizational change to help restore public confidence in the death investigation system following the Inquiry into Pediatric Forensic Pathology in Ontario.
- Forensic pathology is a rapidly evolving discipline, impacted by technological and scientific advances and an expanded role for forensic pathologists as coroners in criminally suspicious and homicide cases.
- Broader ministry and government mandates (e.g., death prevention, public health, poverty reduction) will require the support of all members of the community safety team.
- There is a commitment to ensure accessible services, products and facilities for our employees and the public we serve.
- Policy development related to social issues and injustices (e.g., First Nations, LGBTQ, socio-economic issues) will continue to drive the demand for data, research and recommendations.
Feedback from Consultations
By engaging with members of the death investigation system (staff, management and fee-for-service professionals), families, and criminal justice, medical and industry stakeholders, we gained valuable insight about our organization from a variety of perspectives province-wide. This information was helpful in providing context for the strategic direction of our division.
For the first time, our strategic planning efforts have been directly influenced by seeking out first-hand feedback from families who have been in contact with Ontario’s death investigation system. This was accomplished through the design and piloting of a family survey. We gained valuable insight into where we do well and where we can improve. The pilot produced some early themes related to the need for better communication and information sharing. While we know we need to learn more from families, this early feedback has been influential in developing this plan and shaping the resulting priorities. Most importantly, we heard from families that they were pleased to have the opportunity to provide their input and help guide the future of this organization as well as our approach to service provision. Our plan will also highlight opportunities to build on this new type of engagement with families and the public.
As part of the strategic planning process, we sought input from our staff across Ontario. Six regional focus groups were conducted, including two Toronto sessions, and one session each in London, Kingston, Sudbury, and Thunder Bay with fee-for-service personnel and stakeholders. An additional four focus groups were conducted with OCC, OFPS, and OSB staff. There was significant alignment in what we heard from our people across these sessions. There was strong support for our medically-led death investigation system, as well as our focus on prevention, public safety, and quality service provision. Furthermore, there was recognition that our system generates extensive data, which we have a responsibility to leverage and share while identifying relevant public safety and health insights and recommendations.
Staff expressed that there is currently some disparity in service provision across regions, and that we must understand the unique needs of each region and align resources to these needs. Additionally, staff indicated that a greater focus on attraction, development, and retention of skilled personnel is required to ensure our people have the right competencies and capabilities to be successful, and that our workforce is sustainable going forwards. Finally, our infrastructure across the province must be modernized to support the delivery of effective and relevant services, as well as collaboration both within our organization and with external partners and stakeholders. Our plan will support progress in each of these areas to ensure that we continue to move closer towards achieving our vision and mission.
Many of the points raised by our staff were also raised by our partners and stakeholders, including praise for the quality and credibility of the medically-led system and the need to understand and mitigate regional service level disparities. Our partners and stakeholders also highlighted that of utmost importance to them is an increased commitment to regular and meaningful consultation and consideration with respect to the input they provide.
Additionally, our people, partners and stakeholders recognize that our system generates extensive data. Further, while we may use the data to inform our investigations and recommendations to improve public safety and health, when shared with researchers and subject-matter experts conducting more extensive studies, it can have a greater, more lasting impact. Given that, we will work with our partners and stakeholders to improve access to the data generated by the death investigation system. Finally, our partners and stakeholders support the continued sustainability of our system, including efforts to build additional links with academic organizations and institutions, expand formal educational opportunities, and develop future talent both within Ontario and abroad.
We recognize that working together with our partners and stakeholders is critical to our future success, and to the improved prevention of premature death, and we are committed to making every effort to provide timely, relevant information and continue to identify opportunities for further collaboration.
The “Strategic Plan for Ontario’s Death Investigation System” outlines the strategic direction for our division over the next five years and provides guidance on realizing our vision and mission.
We have identified actions to facilitate building a modern and sustainable system that allow us to meet our objectives: effectively provide death investigation services; generate knowledge from our findings; and ultimately, improve the safety and health of Ontarians. While this strategy sets our path forward for the next five years, we will be relying on our most valuable assets to bring this strategy to life - our people.
Our Vision and Mission
- High-quality death investigation for a safer and healthier Ontario.
- To provide high-quality death investigation that supports the administration of justice, the prevention of premature death, and is responsive to Ontario’s diverse needs.
As we work towards achieving our vision and mission, we will consider the needs of the individuals and organizations with which we interact, including families and members of the public; Ontario’s criminal justice system; the Ministry of Community Safety and Correctional Services and the Death Investigation Oversight Council. In addition to these key groups, we will also work closely with academic and educational institutions, research organizations, and not-for-profit organizations working across sectors to generate new insights and recommendations to prevent premature deaths and improve the safety and health of Ontarians.
Our division shares core values that speak to our commitment to public service, and are reflected through our actions. Our values are integrated and guide our activities and decisions. We encourage the practical application of these core values through the culture we create, the work that we do, and the services we provide.
Our values include:
We remember that the pursuit of truth, honesty and impartiality is the cornerstone of our work.
We embrace opportunities, change and innovation.
We constantly strive towards best practice and best quality.
We recognize the importance of our work and will accept responsibility for our actions.
We respect a diverse team with different backgrounds, professional training and skills.
Objectives and Supporting Actions
Our strategic plan is built on four interrelated priorities:
- A sustainable and effectively resourced system
- Effective, relevant, and reliable services
- Leverage data, build knowledge, and provide education
- Improve the health and safety of Ontarians
At its core, the system is built on its people, systems, technology and infrastructure. Our objective is to ensure this core is solidly developed in order to effectively sustain and support the growth and development in adjacent areas. The visual depicts that each priority or layer is foundational for the next and as we move further from our core, we have greater opportunities for future development and growth.
From each priority stems a strategic objective or desired state that we aspire to reach over the course of the next five years. We have outlined examples of key high-level actions for achieving the objectives and how we can measure progress. These actions provide early guidance for our comprehensive operational and business plans.
The measures to indicate progress will allow us to identify when we have completed the activities we have outlined, and demonstrate our progress as we continue to move closer to achieving our objectives. We will use these and other measures to track the implementation of our strategic plan. As our objectives are interconnected, our progression will be determined based on the completion of actions across all objectives. However, we recognize that our objectives build on each other, and progress as indicated in our measures may be achieved sooner in some areas than others. These measures will continue to evolve as we collectively work together to determine how we can achieve our objectives.
Priority 1: A Sustainable and Effectively Resourced System
Strategic Objective #1
Provincial complement of highly qualified human resources, supported by modern processes, systems, infrastructure and technology
Action 1.1 - Develop a technology strategy to respond to today’s requirements, future needs and plan new investments based on priorities.
Action 1.2 – Implement a plan to develop, attract and retain a highly competent and engaged provincial workforce for a sustainable death investigation system.
Action 1.3 - Maximize our use of current assets and develop a plan for current and future provincial needs to ensure access to modern infrastructure.
Action 1.4 – Deliver an integrated death investigation system to effectively manage cases, collect and monitor data to identify emerging trends, support research and enable collaboration.
How We Will Measure Progress
Some examples of the measures that will demonstrate progress in achieving a sustainable and effectively resourced system include:
- Implementation and communication plans to support the delivery of the strategic plan.
- A dedicated workforce of professionals with the relevant core competencies.
- Recruitment and retention strategies.
- A modernized, employment relationship with fee-for-service professionals.
- A multi-year technology plan that provides the roadmap for meeting our information technology requirements.
- An information management plan that supports and facilitates collecting high-quality data through the death investigation process.
- An infrastructure and asset management plan to improve province-wide access to modern infrastructure.
- High levels of employee engagement and workforce satisfaction.
- An enhanced number of divisional interdisciplinary working groups.
Priority 2: Effective, Relevant, and Reliable Services
Strategic Objective #2
System delivers effective and efficient investigation and certification of deaths, and high-quality forensic medicine and autopsy services
Action 2.1 - Engage in regular and meaningful consultation to deliver services that are responsive to the diverse needs of families, stakeholders, and the criminal justice system.
Action 2.2 - Provide reliable and sustainable death investigation services across Ontario by optimizing regional service delivery, aligning resources to the diverse needs of the system thereby ensuring accessible service delivery.
Action 2.3 - Implement a division-wide Quality Management System that provides the framework for ongoing performance evaluation, outcome measurement, reporting and continuous improvement.
Action 2.4 – Develop a unified external brand to provide system users with greater clarity and facilitate ease of access, as well as enhance internal collaboration and communication.
How We Will Measure Progress
Some examples of the measures that will demonstrate we have achieved effective, relevant and reliable services include:
- Improvement in responsiveness to family and public requirements, through the implementation of a system-wide family/public feedback survey.
- A division-wide Quality Management System with enhanced performance measures for timeliness and accuracy that meet or exceed agreed upon standards and industry best practices.
- A unified external brand and public education campaign for greater clarity and accessibility by 2017.
- Expanded and improved regional service delivery capacity with more cases being managed locally/regionally.
- Forensic-pathologist coroners practicing in all regions of the province.
- Enhanced capacity in northern and Aboriginal communities with reliable and expanded access to coroner and forensic pathology services such as:
- Establishing a centre of excellence for forensic pathology in Sault Ste. Marie, and increasing capacity in northwestern Ontario through the Residency Training Program
- The development of innovative approaches to service delivery.
- A stakeholder/partner engagement and consultation plan with annual reporting on feedback and outcomes.
Priority 3: Leverage Data, Build Knowledge, and Provide Education
Strategic Objective #3
Robust data creates knowledge and drives education and innovation in death investigation and forensic medicine
Action 3.1 - Implement a data management plan to capture, track and analyze information to make meaningful and measurable contributions to health and public safety.
Action 3.2 - Strengthen the division’s research capabilities and contributions to death investigation, forensic medicine, public safety and health, while building capacity to partner with other organizations to advance research and recommendations.
Action 3.3 - Deliver enhanced continuing education and professional development (CEPD) for staff and professionals working in the death investigation system, ensuring that these opportunities are made available across Ontario.
Action 3.4 – Through knowledge sharing, support the education and capacity development of other professionals and partners working with the death investigation system in Ontario, Canada and internationally.
How We Will Measure Progress
Some examples of the measures that will demonstrate we have leveraged data, built knowledge and provided education include:
- A data management plan that supports data driven public safety.
- The capacity for dynamic analysis to assess for emerging trends and areas of interest across the broader public safety and health sectors.
- Increased contribution to research and a measurable presence in peer reviewed publications.
- Dedicated time allotted to conducting research and sharing knowledge internally and externally.
- A robust continuing education and professional development (CEPD) program for professionals involved in Ontario’s death investigation system including an accredited training program for coroners.
- Greater participation through enhanced regional program delivery and increased accessibility through technology.
- Sustainable partnerships with academic institutions and build on the current relationship with the Centre of Forensic Science and Medicine at the University of Toronto.
- Host the International Association of Forensic Science (IAFS) Conference in 2017 to advance knowledge in forensic medicine and death investigation.
Priority 4: Improve the Health and Safety of Ontarians
Strategic Objective #4
Enhanced review mechanisms and stronger partnerships contribute to a safer and healthier Ontario
Action 4.1 – Evaluate and promote innovative death review and recommendation processes, including inquests, by reviewing their structure and approach, and evaluating outcomes.
Action 4.2 - Cultivate relationships with key partners to develop strategies that harness our knowledge to create measurable outcomes and make positive impacts on public safety.
Action 4.3 - Provide partners and organizations with easy access to knowledge, research output and recommendations that will inform public safety and health initiatives.
Action 4.4 - Embrace Open Government by proactively making available appropriate data in digital format.
How We Will Measure Progress
Some of the examples that will demonstrate how we have helped to improve the safety and health of Ontarians include:
- Transferable and accessible data, including all appropriate data available in digital format by 2020.
- Improved inquest, death review, and recommendation processes.
- Productive partnerships, e.g., increased number of tissue donors through partnership with the Trillium Gift of Life.
- Demonstrated a reduction in years of life lost from premature and preventable death. Enhanced public confidence in the death investigation system.
- A plan to continuously evaluate and improve the quality of future recommendations.
- Track the frequency of recommendations being translated into practice, policy or legislation.
- Strategic partnerships to advance broader prevention mandates.
Enablers for Success
What will it take to bring our strategic plan to life? We will rely on the following enablers to remain agile and responsive and to implement the priorities that have been set out in this plan.
A Commitment to Implementation
Implementation of this plan will require the commitment and effort from all levels of the organization, effective project management, oversight and transparency. We will need to balance operational pressures and fiscal realities with achieving our strategic objectives. That may mean making choices about what happens early into our five-year journey, and what may come later. Finally, we will continually monitor our performance against set targets to find opportunities to improve efficiency and invest in the areas with potential for the most relevant and meaningful outcomes. We have outlined examples of the measures against which we will monitor progress for each of our objectives within this plan, and will continue to define appropriate targets for each so that we can clearly benchmark our progress and ensure our plan is implemented on time and on budget.
Communication and transparency is critical during times of change. Through open and ongoing dialogue, we will create momentum required to advance our aspirational plan and ensure a full understanding of the path ahead and the steps to be taken. This is integral to maintaining effective relationships with internal and external partners that are vital to the implementation of this plan and our long-term operations. We will build a communications strategy to support regular updates and a forum to learn more about the impact our plan is having across the system.
Fostering and enhancing partnerships are key to achieving our objectives and improving outcomes. We must identify mutually beneficial partnerships and nurture the relationships through ongoing collaboration and communication. In times of fiscal constraint, partnerships will help us do more with less and combine resources for shared success. Also, information and data will be shared with our partners so that they have the ability to complete research and effectively advocate for meaningful public safety and health initiatives. They can also play a key role in translating the recommendations of Ontario’s death investigation system into practice.
While this document sets the strategic direction for our division for the next five years, our people will develop specific activities to achieve the objectives in their areas. As a whole, our workforce must have a culture committed to public service, quality and teamwork. There will be an expectation for an organizational commitment to knowledge transfer across what may have once been considered professional barriers. We will be informed by our history and experience, but focus on the future in embracing data, evidence and new ways of doing business. This will inspire an atmosphere of innovation and continuous improvement where our team can thrive.
Over time, the system has evolved into three individual branches. While internally this has made sense, does it resonate from a public lens? Families and other stakeholders are supported by the services of Ontario’s death investigation system as a whole. Often, they do not recognize the differences in roles and responsibilities between the OCC and OFPS, particularly during times of grief and sudden change in their personal lives. As part of the strategic planning exercise, we discussed with our staff, partners and stakeholders the concept of a “common identity” or “brand” for Ontario’s death investigation system.
Through consultation, we heard that both the OCC and the OFPS have unique strengths, history, and experiences. Each organization is proud of its identity. We recognize and endorse the commitment of our workforce to their respective organizations. In response to this, in addition to the crest and visual identifier for the OCC, we are pleased to officially launch the visual identity and logo of the OFPS. These organizational badges and mottos are a testament to the commitment and hard work of the people who work for these organizations.
Our future identity
We also recognize that going forward we must continue to do a better job at providing public education about the role the province has in reportable deaths and facilitating interface with our public and families through a unified identifier. We heard from many of our staff, the families and external stakeholders we serve that a unified external identity would encourage greater collaboration and facilitate navigating and interacting through our complex system. As such, we are committed to developing a unified external brand that incorporates the OCC and the OFPS, as well as the OSB, representing all of Ontario’s death investigation system. We look forward to further engagement and consultation on this exciting endeavour and commit to deliver a new unified identity for Ontario’s death investigation system by 2017.
The success of this strategic plan is dependent upon the support and collaboration of all our people. They will transform this plan into action to ensure high-quality death investigations for families, the public and the criminal justice system.
We would like to express our gratitude to those who graciously committed their time and effort to the strategic planning process. From their insights, to the critical thinking and tremendous energy contributed, we want to recognize and thank all of our staff, partners, stakeholders and families who participated in this engagement. Your time, effort and input have resulted in a more comprehensive strategic plan that will undoubtedly position us to meet and deliver on the challenges of the future and keep Ontario among the world leaders in death investigation.