Office of the Chief Coroner
2008 Report on Inquests

October 2010

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Download the PDF – 172 KB

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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

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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

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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.

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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)

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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.

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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.

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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.

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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.

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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.)

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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

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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						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	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	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

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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

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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

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

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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	4
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

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

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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: 17

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

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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

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

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Summary of Inquests – 2008

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

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

Figure 7 Average Number of Days per Inquest.

Figure 8 Average Response Rate, Inquest Type, 2008.

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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

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

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

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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%

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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

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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.

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

Figure 12 Number of Discretionary Inquests, 2002 - 2008.

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

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

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

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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

Figure 16 Total Number of Recommendations, 2002 - 2008.

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

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

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

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

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

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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

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

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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.

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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.

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

Figure 24 Inquests With No Recommendation Total 2002 – 2008.

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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

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

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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