Ministry of Community Safety and Correctional Services :: Reports on Inquests

Office of the Chief Coroner
2008 Report on Inquests

October 2010


Download the PDF – 172 KB


Table of Contents

Executive Summary

Introduction
The Five Questions

When an Inquest is Called

What an Inquest is Not

Verdicts and Recommendations

Method for Distributing Inquest Recommendations

Evaluation of Responses

Comments on the 2008 Report

2007 Inquests
Comprehensive Report on 2008 Inquests

Summary of Inquests (2008) – Based on Type of Inquest
Summary – Discretionary Inquests (2008)

Summary – Mandatory Custody Inquests (2008)

Summary – Mandatory Construction Inquests (2008)

Summary – Mandatory Mining Inquests (2008)

Summary – All Inquests (2008)

Comparison of Inquest Type and Manner of Death (2008)

Inquests with No Recommendations (2008)

Manner of Death for Inquests with no Recommendations

Historical Analysis of Inquests (2002 – 2008)

Number of recommendations per inquest (2002 – 2008)

Average number of days per inquest (2002 – 2008)

Implementation of recommendations (2002 – 2008)

Inquests with no recommendations (2002-2008)

Rates of responses to recommendations (2002-2008)

Analysis of Responses to Recommendations from Individual Inquests

Contact


2008 Executive Summary

  • 76 inquests were held in 2008
  • 4% of the inquests conducted were discretionary
  • 96% of the inquests conducted were mandatory (custody, construction and mining)
  • 71% were custody
  • 22% were construction
  • 3% were mining
  • 28% of the inquests resulted in no recommendations
  • a total of 423 recommendations were made
  • on average, 75% of the organizations asked to respond, did so
  • on average, each inquest in 2008 lasted 3 days

According to the responses received regarding recommendations:

  • 40% have been implemented
  • 6% will be implemented
  • 21% have had alternates implemented
  • 24% will have alternates implemented
  • 11% are under consideration
  • 0.5% have unresolved issues
  • 3% were rejected with no specific reason given
  • 1% were rejected due to flaws
  • 0.5% were rejected due to lack of resources
  • 10% did not apply to the agency assigned
  • 12% no response received
  • 1% received responses that could not be evaluated

Of the deaths inquested in 2008:

  • 37% were natural
  • 43% were accidental
  • 9% were suicides
  • 8% were homicides
  • 3% were undetermined
  • 100% of the construction inquests and mining inquests were accidental deaths

Introduction

The inquest has its origins in eleventh century England. When a body was found, a representative of the Crown had to decide five things:

  1. Who was the deceased?
  2. Where did he or she die?
  3. When did he or she die?
  4. How did he or she die?
  5. Who was to blame?

(NOTE: blame can no longer be assigned by inquest)

To help the “Crowner” (or “Coroner”) decide these five questions, he summoned all the men from the surrounding villages to give evidence. Later, this evolved into a jury selected to hear the evidence.

The role of the coroner has been modified over the centuries. Today in Ontario, coroners are physicians appointed to serve the communities in which they live. The duties, activities and powers of coroners are defined in the Coroners Act, 1990. This Act is the legislated authority and reference for inquests. Death investigation is a provincial jurisdiction and other provinces and territories may have different systems and legislation governing the proceedings they conduct.


The Five Questions

There are five questions that must be answered when investigating a death:

  1. Who was the deceased?
  2. Where did the death occur?
  3. When did the death occur?
  4. How did the death occur (i.e. the medical cause)?
  5. By what means did the death occur (i.e. the classification or manner of death)?

(“By what means” refers to the following categories: Natural, Accident,

Homicide, Suicide, and Undetermined)


When an Inquest is called

There are two types of inquests: mandatory and discretionary. Mandatory inquests are conducted pursuant to legislative requirements under the Coroners Act. In 2005, deaths arising from accidents in the course of employment at construction, mining, pit or quarry sites and deaths occurring while being detained or in custody, required a mandatory inquest. In 2007, the legislation was amended to include mandatory inquests for children who die under very specific circumstances. All other inquests are considered discretionary and may be conducted in accordance with section 20 of the Coroners Act.

In July of 2009, the legislation was again amended so that natural deaths in correctional custody occurring on or after July 27, 2009 will no longer require an inquest to be held; and deaths occurring in psychiatric facilities which involve physical restraints on or after July 27, 2009 will require an inquest to be held. These amendments to the Coroners Act do not impact the 2008 statistics on inquests.

There are several factors that a coroner takes into account when deciding whether to hold a discretionary inquest. For instance, the coroner must consider whether the answers to the five questions are known. The coroner may also determine whether or not it is desirable for the public to have an open and full hearing of the circumstances of a death. Additionally, an inquest allows juries to make useful recommendations to prevent other deaths in similar circumstances. This preventative function is a very important aspect of inquests, because it encourages changes that will result in a safer province. Recommendations from previous inquests have resulted in changes to legislation (e.g. graduated licensing and labour laws), policy (e.g. how the police and courts administer justice), procedures (e.g. how we protect children and how safe medical practices are encouraged) and product development (e.g. safety mechanisms for motorized vehicles and other consumer goods).

There is no time limit between the date of death and the convening of an inquest.


What an Inquest is NOT

An inquest is NOT an adversarial process. It is not a trial, a process for discovery, a royal commission or a campaign directed by personal or philosophical agendas. An inquest is an inquisitorial process designed to focus public attention on the circumstances of a death and it is a dispassionate public examination into the facts.


Verdicts and Recommendations

The jury must answer the five questions: who, when, where, how and by what means. It is the jury, not the coroner or any other party involved in the inquest, who ultimately decides on the answers to those questions based on the evidence heard.

Juries may make recommendations to prevent deaths in similar circumstances. It is through the recommendations made by coroner’s juries that significant changes are made to improve the safety and quality of life in Ontario. In some inquests, the jury may not feel that any recommendations are necessary.

Organizations and agencies that are asked to address inquest recommendations suggested by the jury are under no legal obligation to implement recommendations and may choose not to respond. Most organizations and agencies however, recognize the valuable and important contribution of jury suggested recommendations and as a result, the majority of recommendations receive some manner of formal acknowledgement or response. The high response rate to recommendations is a credit to the integrity and effectiveness of the inquest jury process.


Method for Distributing Inquest Recommendations

The presiding inquest coroner encourages the jury to submit their recommendations grouped under the headings, which reflect the agency, ministry, organization or entity to which the recommendation should be directed. Inquest staff at the Office of the Chief Coroner review and distribute the recommendations to agencies, ministries and organizations identified by the juries, together with a covering letter, requesting the respondent to inform the Office of the Chief Coroner regarding the implementation of recommendations.

For inquests taking place in 2006 and onwards, the Office of the Chief Coroner amended its procedures and encourages responses within one year from the actual completion of the inquest. After the one-year period, a final report on each inquest is prepared.


Evaluation of Responses

Organizations and agencies asked to respond to recommendations are given the opportunity to evaluate their own responses based on the codes listed below. Responses that are not “self-analyzed” are reviewed by staff at the Office of the Chief Coroner and assigned appropriate response codes.

Responses to jury recommendations are evaluated according to the following codes:

Response

Code

Explanation

1

Recommendation has been implemented.

1A

Recommendation will be implemented.

1B

Alternative recommendation has been implemented.

1C

Alternative recommendation will be implemented.

2

The recommendation is under consideration.

3

There are unresolved issues with the recommendation that need to be addressed.

4

The recommendation is rejected.

4A

The recommendation is rejected due to flaws.

4B

The recommendation is rejected due to lack of resources.

5

The recommendation did not apply to the agency assigned.

6

There was no response to the recommendation.

7

The response could not be evaluated (e.g.: response was vague, response did not address stated recommendation, etc.)


Comments on 2008 Report on Inquests

Comments regarding this report may be submitted to:

Executive Officer, Inquests and Special Projects
Office of the Chief Coroner
26 Grenville Street
Toronto, Ontario
M7A 2G9

Additional copies of reports can be obtained by contacting Pat Campbell in the Office of the Chief Coroner at 416-314-4025, 1-877-991-9959 or by email Pat.Campbell@ontario.ca


Comprehensive Report on 2008 Inquests

Response Codes

 

Inquest Number

# Recs

Inquest Type

By What Means

# Days

# Orgs. Asked To Respond

% Responses

1

1A

1B

1C

2

3

4

4A

4B

5

6

7

1

2008-01

6

Cust

S

3

2

100

4

 

 

 

 

 

2

 

 

 

 

 

2

2008-02

12

Cust

A

15

7

86

1

 

 

 

4

 

 

 

 

 

 

3

2008-03

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

4

2008-04

3

Cust

N

2

1

0

0

 

 

 

 

 

 

 

 

 

 3

 

5

2008-05

8

Cust

H

6

2

100

6

 

 

 

 

 

1

 

1

1

 

 

6

2008-06

2

Cust

A

3

1

100

2

 

 

 

 

 

 

 

 

 

 

 

7

2008-07

1

Cust

S

2

1

100

 

 

 

1

 

 

 

 

 

 

 

 

8

2008-08

0

Cust

A

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

9

2008-09

1

Cust

N

2

1

100

1

 

 

 

 

 

 

 

 

 

 

 

10

2008-10

14

Cust

N

7

6

100

6

 

 

1

1

 

1

 

 

3

4

 

11

2008-11

0

Cust

N

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

12

2008-12

5

Cust

N

1

1

100

5

 

 

 

 

 

 

 

 

 

 

 

13

2008-13

2

Const

A

2

1

100

2

 

 

 

 

 

 

 

 

 

 

 

14

2008-14

4

Const

A

2

4

50

1

 

 

 

1

 

 

 

 

3

 

 

15

2008-15

1

Cust

A

2

1

100

1

 

 

 

 

 

 

 

 

 

 

 

16

2008-16

3

Cust

N

4

4

50

 

 

2

 

 

 

 

 

 

 

 

 

17

2008-17

4

Cust

N

3

1

100

3

 

 

`

 

1

 

 

 

 

 

 

18

2008-18

1

Cust

S

5

1

100

1

 

 

 

 

 

 

 

 

 

 

 

19

2008-19

4

Cust

A

4

5

80

2

 

2

 

 

 

 

 

 

1

 

20

2008-20

9

Const

A

2

3

67

3

 

 

 

 

 

 

 

 

5

 1

 

21

2008-21

3

Cust

N

2

1

100

2

1

 

 

 

 

 

 

 

 

 

 

22

2008-22

6

Const

A

2

2

50

 

 

 

 

2

 

1

 

 

 

 3

 

23

2008-23

14

Cust

A

3

3

67

7

 

4

 

2

 

1

 

 

 

 

 

24

2008-24

16

Mining

A

5

1

100

12

 

 

 

4

 

 

 

 

 

 

 

25

2008-25

2

Cust

S

1

1

100

1

 

 

 

 

 

 

 

 

 

 

1

26

2008-26

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

27

2008-27

10

Disc

A

7

1

100

3

1

3

 

 

 

1

2

 

 

 

 

28

2008-28

12

Mining

A

4

6

33

1

 

1

 

1

 

 

 

 

1

8

 

29

2008-29

0

Cust

S

3

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

30

2008-30

7

Const

A

1

2

50

7

 

 

 

 

 

 

 

 

1

 

 

31

2008-31

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

32

2008-32

4

Const

A

2

1

100

4

 

 

 

 

 

 

 

 

 

 

 

33

2008-33

0

Const

A

3

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

34

2008-34

15

Cust

H

6

5

80

12

 

1

 

2

 

2

 

 

9

 

 

35

2008-35

1

Cust

U

3

1

100

1

 

 

 

 

 

 

 

 

 

 

 

36

2008-36

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

37

2008-37

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

38

2008-38

14

Cust

N

6

3

100

5

4

6

 

1

 

 

 

 

 

 

 

39

2008-39

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

40

2008-40

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

41

2008-41

2

Const

A

2

1

100

2

 

 

 

 

 

 

 

 

 

 

 

42

2008-42

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

43

2008-43

1

Cust

N

1

1

500

2

 

 

 

 

 

 

 

 

3

 

 

44

2008-44

5

Cust

A

4

4

100

2

 

2

 

2

 

 

 

 

 

 

 

45

2008-45

5

Cust

N

2

1

100

5

 

 

 

 

 

 

 

 

 

 

 

46

2008-46

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

47

2008-47

5

Const

A

2

2

50

1

 

 

1

 

 

 

 

 

 

 

 

48

2008-48

2

Const

A

1

1

100

1

 

 

 

 

 

 

 

 

1

 

 

49

2008-49

19

Cust

H

7

1

100

13

2

4

 

 

 

 

 

 

 

 

 

50

2008-50

3

Cust

A

2

1

100

1

 

2

 

 

 

1

 

 

 

 

 

51

2008-51

66

Cust

N

20

11

109

24

10

9

1

13

1

3

2

 

7

 5

 

52

2008-52

10

Disc

A

5

6

0

 

 

 

 

 

 

 

 

 

 

 10

 

53

2008-53

19

Const

A

4

3

67

5

2

3

5

3

 

 

 

 

 1

 

 

54

2008-54

10

Cust

N

2

1

0

 

 

 

 

 

 

 

 

 

 

10

 

55

2008-55

4

Cust

S

2

1

100

2

 

2

 

 

 

 

 

 

 

 

 

56

2008-56

6

Disc

A

3

1

100

5

 

1

 

 

 

 

 

 

 

 

 

57

2008-57

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

58

2008-58

3

Cust

A

4

5

80

1

 

1

 

1

 

 

 

 

1

 

 

59

2008-59

9

Cust

N

4

1

100

1

5

1

 

 

 

 

1

1

 

 

 

60

2008-60

10

Const

A

4

2

50

 

 

10

 

 

 

 

 

 

 

 

 

61

2008-61

0

Const

A

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

62

2008-62

11

Cust

N

3

4

75

3

 

 

 

5

 

 

 

 

1

 

2

63

2008-63

3

Cust

A

2

1

100

3

 

 

 

 

 

 

 

 

 

 

 

64

2008-64

16

Const

A

3

2

50

 

 

16

 

 

 

 

 

 

 

 

 

65

2008-65

6

Const

A

3

2

150

 

 

6

1

 

 

 

 

 

 

 

 

66

2008-66

0

Cust

U

5

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

67

2008-67

12

Cust

H

10

7

71

4

1

8

 

1

 

 

 

 

3

 

1

68

2008-68

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

69

2008-69

6

Cust

N

3

4

75

3

 

 

 

2

 

 

 

 

1

 

 

70

2008-70

3

Cust

H

1

1

100

 

 

3

 

 

 

 

 

 

 

 

 

71

2008-71

1

Const

A

1

1

100

 

 

1

 

 

 

 

 

 

 

 

 

72

2008-72

0

Cust

S

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

73

2008-73

2

Const

A

2

1

100

 

 

2

 

 

 

 

 

 

 

 

 

74

2008-74

0

Cust

A

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

75

2008-75

0

Cust

H

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

76

2008-76

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 
 

Total

423

   

237

135

91

171

26

90

10

45

2

13

5

2

42

52

4

 

 

 

Percentage of Total Response Codes

37

6

20

2

10

0

3

1

0

9

11

1

Note: The number of responding organizations, in some cases, exceeded the actual number of organizations asked to respond. Therefore, the total number of responses is greater than the total number of recommendations.

Cust = custody
Const = construction
Disc = discretionary
N=natural
A=accident
S=suicide
H=homicide
U=undetermined


Summary of Inquests (2008) – Based on Type of Inquest

Type

Total # of Recs

Total # of Recs

Total # of Inquests

% of Total Inquests

Avg # of Recs per Inquest

Avg % of Response Rate

Total # Days in Inquest

Avg # Days in Inquest

Discretionary

26

6

3

4

9

67

15

5

Custody

274

65

54

71

5

100

176

3

Construction

95

22

17

22

6

79

37

2

Mining

28

7

2

3

14

67

9

5

This image is a pie chart which shows the percentage of inquests by type. 71% Custody, 3 percent Mining, 4% Discretionary and 22% Construction.


Summary – Discretionary Inquests 2008

Inquest Type: Discretionary

#

Inquest

#

# Recs

Inquest Type

By What Means

# Days

# Orgs. Asked to Resp.

% Resp.

1

1A

1B

1C

2

3

4

4A

4B

5

6

7

27

2008-27

10

Disc

A

7

1

100

3

1

3

     

1

2

       

52

2008-52

10

Disc

A

5

6

0

                   

10

 

56

2008-56

6

Disc

A

3

1

100

5

 

1

                 
 

Total

   

15

8

67

8

1

4

0

0

0

1

2

0

0

10

0

   

Percentage of Total Response Codes

31

4

15

0

0

0

4

8

0

0

38

0

Total number of discretionary inquests: 3

This image is a bar chart displaying the percentage of response codes for Discretionary Inquests.
Response Code: 1-31%, 1A-4%, 1B-15%, 4-4%, 4A-8%, 6-38%. Response Codes 1C, 2, 3, 4B, 5 and 7 had no response.

Figure 1 Percentage of Response Codes for Discretionary Inquests - 2008.

Response Code Legend:

1. Has been implemented
1A. Will be implemented
1B. Alternate has been implemented
1C. Alternate will be implemented
2. Under consideration
3. Unresolved issues
4. Rejected
4A. Rejected due to flaws
4B. Rejected due to lack of resources
5. Did not apply to agency assigned
6. No response
7. Unable to evaluate


Summary – Mandatory Custody Inquests 2008

Inquest Type: Custody (Mandatory)

Response Codes

 

Inquest Number

# Recs

Inquest Type

By What Means

# Days

# Orgs. Asked To Respond

% Responses

1

1A

1B

1C

2

3

4

4A

4B

5

6

7

1

2008-01

6

Cust

S

3

2

100

4

 

 

 

 

 

2

 

 

 

 

 

2

2008-02

12

Cust

A

15

7

86

1

 

 

 

4

 

 

 

 

 

7

 

3

2008-03

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

4

2008-04

3

Cust

N

2

1

0

0

 

 

 

 

 

 

 

 

 

 3

 

5

2008-05

8

Cust

H

6

2

100

6

 

 

 

 

 

1

 

1

1

 

 

6

2008-06

2

Cust

A

3

1

100

2

 

 

 

 

 

 

 

 

 

 

 

7

2008-07

1

Cust

S

2

1

100

 

 

 

1

 

 

 

 

 

 

 

 

8

2008-08

0

Cust

A

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

9

2008-09

1

Cust

N

2

1

100

1

 

 

 

 

 

 

 

 

 

 

 

10

2008-10

14

Cust

N

7

6

100

6

 

 

1

1

 

1

 

 

3

 

11

2008-11

0

Cust

N

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

12

2008-12

5

Cust

N

1

1

100

5

 

 

 

 

 

 

 

 

 

 

 

15

2008-15

1

Cust

A

2

1

100

1

 

 

 

 

 

 

 

 

 

 

 

16

2008-16

3

Cust

N

4

4

50

 

 

2

 

 

 

 

 

 

 

 

 

17

2008-17

4

Cust

N

3

1

100

3

 

 

`

 

1

 

 

 

 

 

 

18

2008-18

1

Cust

S

5

1

100

1

 

 

 

 

 

 

 

 

 

 

 

19

2008-19

4

Cust

A

4

5

80

2

 

2

 

 

 

 

 

 

1

 1

 

21

2008-21

3

Cust

N

2

1

100

2

1

 

 

 

 

 

 

 

 

 

 

22

2008-22

6

Const

A

2

2

50

 

 

 

 

2

 

1

 

 

 

 

 

23

2008-23

14

Cust

A

3

3

67

7

 

4

 

2

 

1

 

 

 

 

 

25

2008-25

2

Cust

S

1

1

100

1

 

 

 

 

 

 

 

 

 

 

 

26

2008-26

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 1

 

29

2008-29

0

Cust

S

3

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

31

2008-31

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

34

2008-34

15

Cust

H

6

5

80

12

 

1

 

2

 

2

 

 

9

 

 

35

2008-35

1

Cust

U

3

1

100

1

 

 

 

 

 

 

 

 

 

 

 

36

2008-36

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

37

2008-37

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

38

2008-38

14

Cust

N

6

3

100

5

4

6

 

1

 

 

 

 

 

 

 

39

2008-39

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

40

2008-40

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

42

2008-42

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

43

2008-43

1

Cust

N

1

1

500

2

 

 

 

 

 

 

 

 

3

 

 

44

2008-44

5

Cust

A

4

4

100

2

 

2

 

2

 

 

 

 

 

 

 

45

2008-45

5

Cust

N

2

1

100

5

 

 

 

 

 

 

 

 

 

 

 

46

2008-46

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

49

2008-49

19

Cust

H

7

1

100

13

2

4

 

 

 

 

 

 

 

 

 

50

2008-50

3

Cust

A

2

1

100

1

 

2

 

 

 

1

 

 

 

 

 

51

2008-51

66

Cust

N

20

11

109

24

10

9

1

13

1

3

2

 

7

 5

 

54

2008-54

10

Cust

N

2

1

0

 

 

 

 

 

 

 

 

 

 

 10

 

55

2008-55

4

Cust

S

2

1

100

2

 

2

 

 

 

 

 

 

 

 

 

57

2008-57

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

58

2008-58

3

Cust

A

4

5

80

1

 

1

 

1

 

 

 

 

1

 

 

59

2008-59

9

Cust

N

4

1

100

1

5

1

 

 

 

 

1

1

 

 

 

62

2008-62

11

Cust

N

3

4

75

3

 

 

 

5

 

 

 

 

1

 

2

63

2008-63

3

Cust

A

2

1

100

3

 

 

 

 

 

 

 

 

 

 

 

66

2008-66

0

Cust

U

5

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

67

2008-67

12

Cust

H

10

7

71

4

1

8

 

1

 

 

 

 

3

 

1

68

2008-68

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

69

2008-69

6

Cust

N

3

4

75

3

 

 

 

2

 

 

 

 

1

 

 

70

2008-70

3

Cust

H

1

1

100

 

 

3

 

 

 

 

 

 

 

 

 

72

2008-72

0

Cust

S

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

74

2008-74

0

Cust

A

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

75

2008-75

0

Cust

H

2

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

76

2008-76

0

Cust

N

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 
 

Total

274

   

176

92

99

124

23

47

3

34

2

11

3

2

30

30

4

 

 

 

Percentage of Total Response Codes

40

7

15

1

10

.5

3

1

.5

10

10

1

Total number of Mandatory Custody Inquests: 54

This image is a bar chart which displays the percentage of Mandatory Custody Inquest response codes.
Response Code: 1-40%, 1A-7%, 1B-15%, 1C-1%, 2-1%, 3-0.5%, 4-3%, 4A, 0.5%, 5-10%, 6-10%, 7-1%.

Figure 2 Percentage of Response Codes for Mandatory Custody Inquests – 2008.


Summary – Mandatory Construction Inquests 2008

Response Codes

 

Inquest Number

# Recs

Inquest Type

By What Means

# Days

# Orgs. Asked To Respond

% Responses

1

1A

1B

1C

2

3

4

4A

4B

5

6

7

13

2008-13

2

Const

A

2

1

100

2

 

 

 

 

 

 

 

 

 

 

 

14

2008-14

4

Const

A

2

4

50

1

 

 

 

1

 

 

 

 

3

 

 

20

2008-20

9

Const

A

2

3

67

3

 

 

 

 

 

 

 

 

5

 1

 

22

2008-22

6

Const

A

2

2

50

 

 

 

 

2

 

1

 

 

 

 3

 

30

2008-30

7

Const

A

1

2

50

7

 

 

 

 

 

 

 

 

1

 

 

32

2008-32

4

Const

A

2

1

100

4

 

 

 

 

 

 

 

 

 

 

 

33

2008-33

0

Const

A

3

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

41

2008-41

2

Const

A

2

1

100

2

 

 

 

 

 

 

 

 

 

 

 

47

2008-47

5

Const

A

2

2

50

1

 

 

1

 

 

 

 

 

 

 

 

48

2008-48

2

Const

A

1

1

100

1

 

 

 

 

 

 

 

 

1

 

 

53

2008-53

19

Const

A

4

3

67

5

2

3

5

3

 

 

 

 

1

   

60

2008-60

10

Const

A

4

2

50

 

 

10

 

 

 

 

 

 

 

 

 

61

2008-61

0

Const

A

1

0

n/a

 

 

 

 

 

 

 

 

 

 

 

 

64

2008-64

16

Const

A

3

2

50

 

 

16

 

 

 

 

 

 

 

 

 

65

2008-65

6

Const

A

3

2

150

 

 

6

1

 

 

 

 

 

 

 

 

71

2008-71

1

Const

A

1

1

100

 

 

1

 

 

 

 

 

 

 

 

 

73

2008-73

2

Const

A

2

1

100

 

 

2

 

 

 

 

 

 

 

 

 
 

Total

95

   

37

28

79

26

2

38

7

6

0

1

0

0

11

4

0

 

 

 

Percentage of Total Response Codes

27

2

40

8

6

0

1

0

0

12

4

0

Total number of Mandatory Construction Inquests: 17This image is a bar chart which displays the percentage of response codes for mandatory construction inquests.
Response Code: 1-27%, 1A-2%, 1B-40%, 1C-8%, 2-6%, 4-1%, 5-12%, and 6-4%
Response codes 3, 4A, 4B and 7 had no response.

Figure 3 Percentage of Response Codes for Mandatory Construction Inquests - 2008.

Response Code Legend:

1. Has been implemented
1A. Will be implemented
1B. Alternate has been implemented
1C. Alternate will be implemented
2. Under consideration
3. Unresolved issues
4. Rejected
4A. Rejected due to flaws
4B. Rejected due to lack of resources
5. Did not apply to agency assigned
6. No response
7. Unable to evaluate


Summary – Mandatory Mining Inquests 2008

Inquest Type: Mining (Mandatory)

Response Codes

 

Inquest Number

# Recs

Inquest Type

By What Means

# Days

# Orgs. Asked To Respond

% Responses

1

1A

1B

1C

2

3

4

4A

4B

5

6

7

24

2008-24

16

Mining

A

5

1

100

12

 

 

 

4

 

 

 

 

 

 

 

28

2008-28

12

Mining

A

4

6

33

1

 

1

 

1

 

 

 

 

1

 8

 
 

Total

28

   

9

7

67

13

0

1

0

5

0

0

0

0

1

8

0

 

 

 

Percentage of Total Response Codes

46

0

3.5

0

18

0

0

0

0

3.5

29

0

Total number of Mandatory Mining Inquests: 2

This image is a bar chart which displays the percentage of response codes for mandatory mining inquests.
Response Code: 1-46%, 1B-3.5%, 2-18%, 5-3.5%, 6-29%.
Response codes 1A, 1C, 3, 4, 4A, 4B, and 7 had no response.

Figure 4 Percentage of Response Codes for Mandatory Mining Inquests – 2008.

Response Code Legend:

1. Has been implemented
1A. Will be implemented
1B. Alternate has been implemented
1C. Alternate will be implemented
2. Under consideration
3. Unresolved issues
4. Rejected
4A. Rejected due to flaws
4B. Rejected due to lack of resources
5. Did not apply to agency assigned
6. No response
7. Unable to evaluate


Summary of Inquests – 2008

This image is a bar chart which displays the average number of recommendations by inquest type.
Construction-6, Custody-5, Mining-14, and Discretionary-4.

Figure 5 Average Number of Recommendations, Inquest Type, 2008.

This image is a pie chart which displays the percentage of total recommendations by type of inquest.
Custody-65%, Mining7%, Discretionary-6% and Construction22%.

Figure 6 Percentage of Total Recommendations, Inquest Type, 2008.

This image is a bar chart which displays the average number of days per inquest. Discretionary-5, Custosy-3, Construction-2, and mining 5.

Figure 7 Average Number of Days per Inquest.

This image is a bar chart which displays the average response rate by type of inquest.
Discretionary-67%, Custody-100%, Construction-79%, and Mining-67%.

Figure 8 Average Response Rate, Inquest Type, 2008.


Comparison of Inquest Type and Manner of Death for 2008 Inquests

Inquest Type

Manner of Death (By What Means)

 

 

Natural

Accident

Suicide

Homicide

Undetermined

Total

Discretionary

0

3

0

0

0

3

Custody

28

11

7

6

2

54

Construction

0

17

0

0

0

17

Mining

0

2

0

0

0

2

Total

28

33

7

6

2

76

 

 

 

 

 

 

 

% of Total

37

43

9

8

3

100

This image is a bar chart which displays a comparison of The type of inquest and the manner of death.
Discretionary: N=0, A=3, S=0, H=0, U=0
Custody: N=28, A=11, S=7, H=6, U=2
Construction: N=0, A=17, S=0, H=0, U=0
Mining: N=0, A=2, S=0, H=0, U=0

Figure 9 Comparison of Inquest Type and Manner of Death, 2008.

This image is a pie chart which displays the percentage of inquests by manner of death.
Accident-43%, Suicide-9%, Homicide-8%, Undetermined-3%, Natural-37%.

Figure 10 Percentage of Inquests, Manner of Death, 2008.


2008 Inquests With No Recommendations

 

Inquest Number

Inquest Type

By What Means

# Orgs. Asked To Respond

3

2008-03

Cust

N

0

8

2008-08

Cust

A

0

11

2008-11

Cust

N

0

26

2008-26

Cust

N

0

29

2008-29

Cust

S

0

31

2008-31

Cust

N

0

33

2008-33

Const

A

0

36

2008-36

Cust

N

0

37

2008-37

Cust

N

0

39

2008-39

Cust

N

0

40

2008-40

Cust

N

0

42

2008-42

Cust

N

0

46

2008-46

Cust

N

0

57

2008-57

Cust

N

0

61

2008-61

Const

A

0

66

2008-66

Cust

U

0

68

2008-68

Cust

N

0

72

2008-72

Cust

S

0

74

2008-74

Cust

A

0

75

2008-75

Cust

H

0

76

2008-76

Cust

N

0

Total number of inquests with no recommendations: 21

% of total inquests in 2008 with no recommendations: 28%


Manner of Death for Inquests with No Recommendations

 

By What Means

 
 

Natural

Accident

Suicide

Homicide

Undetermined

TOTAL

Inquest Type

           

Custody

13

2

2

1

1

19

Construction

0

2

0

0

0

2


Historical Analysis of Inquests 2002-2008

 

2002

2003

2004

2005

2006

2007

2008

Total Number of Inquests

72

74

57

80

53

59

76

Number of Construction Inquests (Mandatory)

13

20

12

23

14

16

17

Number of Custody Inquests (Mandatory)

40

41

29

39

35

35

54

Number of Mining Inquests (Mandatory)

1

6

5

3

1

4

2

Total Number of Mandatory Inquests

54

67

46

65

50

55

73

Total number of Discretionary Inquests

18

7

11

15

3

4

3

Note: Percentages may not equal 100 due to rounding off.

This image is a bar chart which displays the total number of inquests per year from 2002 to 2008.
2002-72, 2003-74, 2004-57, 2005-80, 2006-53, 2007-59, and 2008-76.

Figure 11 Total Number of Inquest Per Year, 2002 - 2008.

This image is a bar chart which displays the number of Discretionary inquests from 2002 to 2008.
2002-18, 2003-7, 2004-11, 2005-15, 2006-3, 2007-4, 2008-3.

Figure 12 Number of Discretionary Inquests, 2002 - 2008.

This image is a bar chart which displays the number of mandatory custody inquests from 2002 to 2008.
2002-40, 2003-41, 2004-29, 2005-39, 2006-35, 2007-35, 2008-54.

Figure 13 Number of Mandatory Custody Inquests, 2002 - 2008.

This image is a bar chart which displays the number of mandatory construction inquests from 2002 to 2008.
2002-13, 2003-20, 2004-12, 2005-23, 2006-14, 2007-16, 2008-17.

Figure 14 Number of Mandatory Construction Inquests, 2002 – 2008.

This image is a bar chart which displays the number of mandatory mining inquests from 2002 to 2008.
2002-1, 2003-6, 2004-5, 2005-3, 2006-1, 2007-4, 2008-2.

Figure 15 Number of Mandatory Mining Inquests, 2002 – 2008.


Average Number of Recommendations Based on Type of Inquest 2002-2008

2002

2003

2004

2005

2006

2007

2008

               

Total number of inquests per year

72

74

57

80

53

59

76

Total number of recommendations per year

537

379

569

621

190

361

423

               

Average number of recommendations per inquest

7.5

5.1

10.0

7.8

3.6

6.1

5.6

Recommendations based on type of Inquest:

             

Number of discretionary inquests

18

7

11

15

3

4

3

Number of recommendations from discretionary inquests

341

67

226

298

35

101

26

Average number of recommendations for discretionary inquests

18.9

9.6

20.5

19.9

11.7

25.2

8.7

               

Number of mandatory inquests (custody, construction and mining)

55

54

67

46

50

55

73

Number of recommendations from all mandatory inquests

322

196

312

343

155

260

397

Average number of recommendations for all mandatory inquests

5.9

3.6

4.7

7.5

3.1

4.7

5.4

               

Number of mandatory custody inquests

40

41

29

39

35

35

54

Number of recommendations from mandatory custody inquests

42

151

173

177

117

125

274

Average number of recommendations for mandatory custody inquests

1.1

3.7

6.0

4.5

3.3

3.6

5.1

               

Number of mandatory construction inquests

13

20

12

23

14

16

17

Number of recommendations from mandatory construction inquests

42

151

127

125

32

105

95

Average number of recommendations for mandatory construction inquests

3.2

7.6

10.6

5.4

2.3

7.5

5.6

               

Number of mandatory mining inquests

1

6

5

3

1

4

2

Number of recommendations from mandatory mining inquests

15

33

43

21

6

30

28

Average number of recommendations for mandatory mining inquests

15

5.5

8.6

7.0

7.0

7.5

14

This image is a bar chart which displays the total number of recommendations for each year from 2002 to 2008.
2002-537, 2003-379, 2004-569, 2005-621,2006-190, 2007-361, 2008-423.

Figure 16 Total Number of Recommendations, 2002 - 2008.

This image is a bar chart which displays the average number of recommendations per inquest per year from 2002 to 2008.
2002-7.5, 2003-5.1, 2004-10, 2005-7.8, 2006-3.6, 2007-6.1, 2008-5.6.

Figure 17 Average Number of Recommendation Per Inquest, 2002 – 2008.

This image is a bar chart which displays the average number of recommendations per Discretionary inquest from 2002 to 2008.
2002-18.9, 2003-9.6, 2004-20.5, 2005-19.9, 2006-11.7, 2007-25.2, 2008-8.7.

Figure 18 Average Number of Recommendations Per Inquest, Discretionary Inquests, 2002 – 2008.

This image is a bar chart which displays the average number of recommendations per Custody inquest from 2002 to 2008.
2002-1.1, 2003-3.7, 2004-6, 2005-4.5, 2006-3.3, 2007-3.6, 2008-5.1

Figure 19 Average Number of Recommendations Per Inquest, Custody Inquests, 2002 – 2008.

This image is a bar chart which displays the average number of recommendations per Construction inquest from 2002to 2008.
2002-3.2, 2003-7.6, 2004-10.6, 2005-5.4, 2006-2.3, 2007-7.5, 2008-5.6.

Figure 20 Average Number of Recommendations Per Inquest, Construction Inquests, 2002 – 2008.

This image is a bar chart which displays the average number of recommendations per Mining inquest from 2002 to 2008.
2002-15, 2003-5.5, 2004-8.6, 2005-7, 2006-7, 2007-7.5, 2008-14.

Figure 21 Average Number of Recommendations Per Inquest, Mining Inquests, 2002 – 2008.


Average Number of Days Per Inquest 2002-2008

 

2002

2003

2004

2005

2006

2007

2008

 

 

 

 

 

 

 

 

Total number of inquests per year

72

74

57

80

53

59

76

Total number of days spent in year

451

237

530

352

220

305

237

 

 

 

 

 

 

 

 

Average number of days per inquest

6.3

3.2

9.3

4.4

4.2

5.2

3

               

Number of discretionary inquests

18

7

11

15

3

4

3

Number of days in discretionary inquests

313

79

258

142

24

101

15

Average number of days for discretionary inquests

17.4

11.3

23.5

9.5

8

23.5

5

 

 

 

 

 

 

 

 

Number of mandatory inquests (custody, construction and mining total)

54

67

46

65

50

55

73

Number of days for mandatory inquests

138

158

272

210

195

204

222

Average number of days for all mandatory Inquests

2.6

2.4

5.9

3.2

3.9

3.7

3

 

 

 

 

 

 

 

 

Number of mandatory custody inquests

40

41

29

39

35

35

54

Number of days for mandatory custody inquests

101

74

164

127

164

136

176

Average number of days for custody inquests

2.5

1.8

5.7

3.3

4.7

3.8

3

 

 

 

 

 

 

 

 

Number of mandatory construction inquests

13

20

12

23

14

15

17

Number of days for mandatory construction inquests

33

65

94

76

29

57

37

Average number of days for construction inquests

2.5

3.3

7.8

3.3

2.1

3.5

2

 

 

 

 

 

 

 

 

Number of mandatory mining inquests

1

6

5

3

1

4

2

Number of days for mandatory mining inquests

4

19

14

7

3

11

9

Average number of days for mining inquests

4

3.2

2.8

2.3

3

2.7

5

This image is a bar chart which displays the avereage number of days per inquest from 2002 to 2008.
2002-6.3, 2003-3.2, 2004-9.3, 2005-4.4, 2006-4.2, 2007-5.2, 2008-3.

Figure 22 Average Number of Days Per Inquest, 2002 – 2008.


Implementation of Recommendations 2002 – 2008

 

2002

2003

2004

2005

2006

2007

2008

Number of recommendations implemented (code 1)

178 (33%)

108 (28.5)

227 (40%)

259 (41.7%)

62 (33%)

125 (39%)

171 (40%)

Number of recommendations that will be implemented (code 1A)

52 (9.7%)

21 (5.5%)

57 (10%)

39 (6.3%)

12 (12%)

28 (9%)

26 (6%)

Number of recommendations with alternates implemented (code 1B)

79 (14.7%)

89 (25.3%)

75 (13%)

95 (15.3%)

19 (10%)

31 (10%)

90 (21%)

Number of recommendations with alternates that will be implemented (code 1C)

81 (15.1%)

11 (2.9%)

14 (2.4%)

13 (2.1%)

2 (2%)

10 (3%)

10 (24%)

Total number of recommendations that have been, or will be implemented, or have or will have alternatives implemented (codes 1, 1A, 1B, 1C)

342 (63.7%)

229 (60.4%)

377 (66%)

406 (65.4%)

108 (56.8%)

194 (60.2%)

297 (70%)

Discretionary Inquests (codes 1, 1A, 1B, 1C)

219 (64%)

41 (18%)

141 (37%)

196 (48%)

14 (48%)

101 (52%)

13 (4%)

               

Mandatory Inquests (Total)

(codes 1, 1A, 1B, 1C)

123 (36%)

186 (81%)

236 (63%)

210 (52%)

211 (58%)

126 (65%)

284 (96%)

               

Custody (codes 1, 1A, 1B, 1C)

84 (25%)

58 (25%)

124 (33%)

111 (27%)

82 (43%)

74 (38%)

197 (66%)

               

Construction (codes 1, 1A, 1B, 1C)

28 (8%)

101 (44%)

84 (22%)

87 (22%)

12 (6%)

47 (24%)

73 (25%)

               

Mining (codes 1, 1A, 1B, 1C)

11 (3%)

27 (12%)

28 (7%)

12 (3%)

17 (8.9%)

5 (3%)

14 (5%)

Number of recommendations under consideration (Code 2)

71 (13.2%)

42 (11.1%)

92 (16%)

81 (13%)

32 (16.8%)

66 (18.2%)

45 (11%)

Number of recommendations with unresolved issues (Code 3)

21 (3.9%)

9 (2.4%)

9 (2.4%)

13 (2.1%)

0 (0%)

5 (1.4%)

2 (0.5%)

Number of recommendations rejected (no specific reason) (Code 4)

34 (6.3%)

18 (4.7%)

23 (4%)

27 (4.3%)

5 (2.63%)

17 (4.7%)

13 (3%)

Number of recommendations rejected due to flaws (Code 4A)

5 (0.9%)

3 (0.8%)

4 (0.7%)

12 (1.9%)

3 (1.57%)

13 (3.6%)

5 (1%)

Number of recommendations rejected due to lack of resources (Code 4B)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

2 (0.5%)

Number of recommendations that did not apply to agency assigned (Code 5)

15 (2.8%)

16 (4.2%)

22 (3.9%)

45 (7.2%)

17 (8.9%)

35 (9.7%)

42 (10%)

Number of recommendations that did not respond (Code 6)

39 (7.3%)

34 (9%)

34 (6.0%)

30 (4.8%)

21 (11%)

27 (7.5%)

52 (12%)

Number of recommendations that could not be evaluated (Code 7)

10 (1.9%)

28 (7.4%)

10 (1.8%)

7 (1.1%)

4 (2.1%)

4 (1.1%)

4 (1%)

Note: Percentages may not be equal 100 due to rounding off.

The number of responding organizations, in some cases, exceeded the actual number of organizations asked to respond. Therefore, the total number of responses is greater than the total number of recommendations.


Inquests With No Recommendations 2002 – 2008

 

2002

2003

2004

2005

2006

2007

2008

Total number of Inquests with NO recommendations (% of total inquests)

15 (21%)

26 (35%)

9 (16%)

14 (17.5%)

19 (35.8%)

14 (24%)

21 (28%)

Discretionary Inquests with no recommendations (% of total inquest with no recommendations)

0

1 (3.8%)

0

0

0

0

0

Mandatory Inquests with no recommendations (% of total inquests with no recommendations)

15 (100%)

25 (96.1%)

9 (100%)

14 (100%)

19 (100%)

14 (100%)

21 (100%)

Custody inquests with no recommendations (% of total inquests with no recommendations)

14 (93%)

22 (84.6%)

9 (100%)

14 (100%)

15 (78.9%)

11 (78.5%)

19 (90%)

Construction inquests with no recommendations (% of total inquests with no recommendations)

1 (7%)

3 (11.5%)

0

0

4 (21%)

3 (21.4%)

2 (10%)

Mining

0

0

0

0

0

0

0

Note: Percentages may not equal 100 due to rounding off.

This image is a bar chart which displays the number of inquests by inquest type with no recommendations from 2002 - 2008.

2002: Discretionary=0, Custody=14, Construction=1, Mining=0
2003: Discretionary=1, Custody=22, Construction=3, Mining=0
2004: Discretionary=0, Custody=9, Construction=0, Mining=0
2005: Discretionary=0, Custosy=14, Construction=0, Mining=0
2006: Discretionary=0, Custody=15, Construction=4, Mining=0
2007: Discretionary=0, Custody=11, Construction=3, Mining=0
2008: Discretionary=0, Custody=19, Construction=2, Mining=0

Figure 23 Inquests With No Recommendations, Inquest Type, 2002 – 2008.

This image is a bar chart which displays the total number and percentage of total of inquests with no recommendations from 2002 to 2008.

2002: Total=15, Percentage=21
2003: Total=26, Percentage=35
2004: Total=9, Percentage=16
2005: Total=14, Percentage=17.5
2006: Total=19, Percentage=35.8
2007: Total=14, Percentage=24
2008: Total=21, Percentage=28

Figure 24 Inquests With No Recommendation Total 2002 – 2008.


Rates of Responses to Recommendations 2002 – 2008

2002

2003

2004

2005

2006

2007

2008

Rates of responses to recommendations (% of organizations asked to respond, that DID respond)

78.5%

80.5%

85.9%

76.7%

70.8%

76.3%

75.3%

Discretionary Inquests

83.9%

71.7%

79.4%

79.9%

71%

65%

67%

Mandatory Inquests (total)

76.1%

83.4%

88%

75.6%

70.8%

72.6%

78%

Custody

47.9%

74.3%

85.2%

89.5%

95.1%

85%

88%

Construction

80.6%

81.4%

88.8%

79.1%

88.4%

77%

79%

Mining

100.0%

94.5%

90%

58.3%

29%

56%

67%

(calculated by averaging the % response rate from all inquests with recommendations)

             

Note: Percentages may not equal 100 due to rounding off.

New codes were introduced in 2000 to reflect recommendations that will be implemented, or Recommendations that will have alternates implemented

This image is a bar chart which displays the rates of responses to recommendations, mandatory (total) and discretionary inquests, from 2002 to 2008.

2002: Discretionary=83.9, Mandatory=76.1
2003: Discretionary=71.7, Mandatory=83.4
2004: Discretionary=79.4, Mandatory=88
2005: Discretionary=79.9, Mandatory=75.6
2006: Discretionary=71, Mandatory 70.8
2007: Discretionary=65, Mandatory=72.6
2008:Discretionary=67, Mandatory=78

Figure 25 Rates of Responses to Recommendations, 2002 – 2008.


Analysis of Responses to Recommendations from Individual Inquests

Analysis of individual inquests is available and can be obtained by contacting Pat Campbell in the Office of the Chief Coroner at 416-314- 4025, 1-877-991-9959 or by email Pat.Campbell@ontario.ca.

Contact

Office of the Chief Coroner
26 Grenville Street
Toronto, ON M7A 2G9
416-314-4000