Government of Ontario
Ministry of the
Solicitor General

Report on Inquests Executive Summary 2012

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Office of the Chief Coroner

2012 Report on Inquests – Executive Summary

November 2014

Print copy – PDF 305 kb

A copy of the full report can be obtained by contacting the Office of the Chief Coroner at 416-314-4000, 1-877-991-9959 or by email at

Executive Summary for inquests completed in 2012

The following statistics reflect inquest recommendations and responses to those recommendations distributed for the year 2012. They are reported in calendar year 2012 as recipients of recommendations are given one year from the date of the conclusion of the inquest to report back to the Office of the Chief Coroner on the status of those recommendations. Respondents self-evaluate based on response codes provided by the Office of the Chief Coroner.

  • 37 inquests were held
  • 24% of the inquests conducted were discretionary
  • 76% of the inquests conducted were mandatory (custody, construction and mining)
  • 43% were custody
  • 56% of the custody inquests involved police custody
  • 30% were construction
  • 3% were mining
  • 11% of the inquests resulted in no recommendations
  • a total of 316 recommendations were made
  • on average, 80% of the organizations asked to respond, did so
  • on average, each inquest in 2012 lasted 6 days

According to the responses received regarding recommendations:

  • 8% have been implemented
  • 4.2% will be implemented
  • 1.8% have had alternates implemented
  • 0% will have alternates implemented
  • 5.6% are under consideration
  • 17.7% content or intent of recommendation already in place
  • 0.3% have unresolved issues
  • 0.4% were rejected with no specific reason given
  • 1.3% were rejected due to flaws
  • 0.4% were rejected due to lack of resources
  • 43.3% did not apply to the agency assigned*
  • 16.2% no response received
  • 0.7% received responses that could not be evaluated

*In many instances the recipient will advise the Office of the Chief Coroner of another organization which may be in a better position to appropriately respond to the recommendation. The recommendation is then redirected to the suggested recipient.

Of the deaths inquested in 2012:

  • 22% were natural
  • 49% were accidental
  • 13% were suicides
  • 16% were homicides
  • 0% were undetermined
  • 100% of the construction inquests and mining inquests were accidental deaths