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

Office of the Chief Coroner for Ontario crest

Office of the Chief Coroner
2009 Report on Inquests

October 2011


Download the PDF – 172 KB


Table of Contents

2009 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

Comprehensive Report on 2009 Inquests

Summary of Inquests (2009) – Based on Type of Inquest

Summary – Discretionary Inquests 2009

Summary – Mandatory Custody Inquests 2009

Summary – Mandatory Construction Inquests 2009

Summary – Mandatory Mining Inquests 2009

Summary of Inquests – 2009

Comparison of Inquest Type and Manner of Death for 2009 Inquests

2009 Inquests With No Recommendations

Manner of Death for Inquests with No Recommendations

Historical Analysis of Inquests 2003-2009

Historical Analysis: Police Custody

Average Number of Recommendations Based on Type of Inquest 2003-2009

Average Number of Days Per Inquest 2003-2009

Implementation of Recommendations 2003 – 2009

Inquests With No Recommendations 2003 - 2009

Rates of Responses to Recommendations 2003 – 2009

Analysis of Responses to Recommendations from Individual Inquests


2009 Executive Summary

  • 72 inquests were held in 2009
  • 1% of the inquests conducted were discretionary
  • 99% of the inquests conducted were mandatory (custody, construction and mining)
  • 68% were custody
  • 18% of the custody inquests involved police custody
  • 25% were construction
  • 6% were mining
  • 36% of the inquests resulted in no recommendations
  • a total of 354 recommendations were made
  • on average, 79% of the organizations asked to respond, did so
  • on average, each inquest in 2009 lasted 3 days

According to the responses received regarding recommendations:

  • 14% have been implemented
  • 10% will be implemented
  • 2% have had alternates implemented
  • 1% will have alternates implemented
  • 17% are under consideration
  • 0.8% have unresolved issues
  • 1% were rejected with no specific reason given
  • 0.2% were rejected due to flaws
  • 0.2% were rejected due to lack of resources
  • 10% did not apply to the agency assigned
  • 0% no response received
  • 0% received responses that could not be evaluated
  • 44% content or intent of recommendation already in place

Of the deaths inquested in 2009:

  • 32% were natural
  • 43% were accidental
  • 11% were suicides
  • 13% were homicides
  • 1% 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:

  • Who was the deceased?
  • Where did he or she die?
  • When did he or she die?
  • How did he or she die?
  • 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 as amended. 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:

  • Who was the deceased?
  • Where did the death occur?
  • When did the death occur?
  • How did the death occur (i.e. the medical cause)?
  • 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 of persons who are committed and who are on the premises of a correctional institution in correctional custody 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 2009 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 during the inquest.

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 addressed. At the direction of the Chief Coroner, 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.)

8*

Content or intent of recommendation already in place

*New code introduced in 2009

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 2009 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

8

1

2009-01

0

Cust

A

3

0

n/a

                         

2

2009-02

1

Const

A

2

1

100

   

1

                   

3

2009-03

7

Disc

A

4

3

67

1

     

5

               

4

2009-04

6

Cust

A

3

3

100

4

1

             

1

     

5

2009-05

3

Cust

H

4

2

50

       

1

       

1

     

6

2009-06

0

Cust

N

1

0

n/a

                         

7

2009-07

0

Cust

S

2

0

n/a

                         

8

2009-08

0

Cust

N

1

0

n/a

                         

9

2009-09

1

Const

A

1

1

100

                       

1

10

2009-10

1

Cust

N

1

2

100

                       

2

11

2009-11

7

Mining

A

3

2

100

 

2

             

5

   

11

12

2009-12

4

Cust

A

3

1

100

2

     

1

             

1

13

2009-13

2

Cust

H

2

1

100

1

   

1

                 

14

2009-14

5

Cust

A

3

5

60

1

             

1

     

5

15

2009-15

0

Cust

N

5

0

n/a

                         

16

2009-16

2

Cust

N

2

2

0

                         

17

2009-17

5

Cust

H

3

7

71

2

     

1

       

3

   

1

18

2009-18

11

Const

A

3

1

100

1

                     

10

19

2009-19

35

Cust

H

10

8

112

2

6

1

 

6

       

5

   

18

20

2009-20

0

Cust

N

1

0

n/a

                         

21

2009-21

7

Cust

S

2

7

50

1

     

1

             

6

22

2009-22

6

Cust

N

2

1

100

           

1

         

5

23

2009-23

1

Cust

A

3

1

100

1

                       

24

2009-24

0

Cust

U

4

0

n/a

                         

25

2009-25

6

Cust

S

2

1

100

 

1

   

1

 

1

         

2

26

2009-26

0

Cust

N

2

0

n/a

                         

27

2009-27

86

Cust

A

34

19

53

4

8

2

 

32

       

8

   

13

28

2009-28

0

Cust

N

1

0

n/a

                         

29

2009-29

10

Const

A

2

6

50

2

     

1

       

4

   

5

30

2009-30

0

Cust

N

4

0

n/a

                         

31

2009-31

2

Const

A

1

4

75

 

2

             

1

   

1

32

2009-32

4

Cust

S

1

1

100

4

                       

33

2009-33

4

Const

A

1

2

100

                       

5

34

2009-34

0

Cust

S

2

0

n/a

                         

35

2009-35

10

Const

A

5

5

80

       

2

       

2

   

6

36

2009-36

3

Const

A

2

1

100

                       

3

37

2009-37

2

Const

A

3

1

100

                       

2

38

2009-38

0

Cust

N

1

0

n/a

                         

39

2009-39

7

Cust

A

8

6

67

1

2

             

3

   

1

40

2009-40

13

Mining

A

2

4

50

       

3

       

1

   

5

41

2009-41

1

Cust

H

3

2

50

                 

1

     

42

2009-42

5

Cust

H

1

1

100

                       

5

43

2009-43

1

Cust

N

1

2

100

                       

2

44

2009-44

0

Cust

N

1

0

n/a

                         

45

2009-45

0

Cust

N

1

0

n/a

                         

46

2009-46

10

Cust

N

7

3

100

4

2

2

           

1

   

4

47

2009-47

2

Cust

S

3

1

100

2

                     

1

48

2009-48

0

Const

A

3

0

n/a

                         

49

2009-49

6

Const

A

2

1

100

                       

6

50

2009-50

0

Cust

H

6

0

n/a

                         

51

2009-51

0

Cust

N

1

0

n/a

                         

52

2009-52

8

Cust

S

8

4

75

3

1

1

 

1

1

1

         

2

53

2009-53

3

Cust

N

1

1

100

           

2

1

         

54

2009-54

0

Cust

A

2

0

n/a

                         

55

2009-55

6

Const

A

2

1

100

                 

1

   

5

56

2009-56

0

Cust

N

1

0

n/a

                         

57

2009-57

0

Cust

N

1

0

n/a

                         

58

2009-58

9

Const

A

2

3

67

1

3

                   

1

59

2009-59

1

Cust

N

2

1

100

                       

1

60

2009-60

0

Cust

S

2

0

n/a

                         

61

2009-61

1

Const

A

2

2

50

                       

1

62

2009-62

0

Cust

N

2

0

n/a

                         

63

2009-63

5

Mining

A

2

1

200

 

1

   

1

             

4

64

2009-64

2

Const

A

2

1

100

                       

2

65

2009-65

7

Cust

N

3

1

100

5

2

                     

66

2009-66

0

Const

A

1

0

n/a

                         

67

2009-67

0

Cust

H

2

0

n/a

                         

68

2009-68

0

Cust

H

3

0

n/a

                         

69

2009-69

22

Mining

A

5

5

100

 

3

   

2

1

           

10

70

2009-70

0

Cust

N

1

0

n/a

                         

71

2009-71

8

Const

A

3

3

100

5

1

1

2

2

             

6

72

2009-72

6

Const

A

2

1

200

2

       

1

           

4

 

Total

354

   

216

129

90

49

35

8

3

60

3

5

1

1

37

0

0

157

 

 

 

Percentage of Total Response Codes

14

10

2

1

17

1

1

0

0

10

0

0

44

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 (2009) – Based on Type of Inquest

Type

Total # of Recs

% of Total Recs

Total # of Inquests

% of Total Inquests

Avg # of Recs per Inquest

Avg % Response Rate*

Total # Days in Inquest

Avg # Days in Inquest

Discretionary

7

2

1

1

7

67

4

4

Custody

218

62

49

68

4

84

161

3

Construction

82

23

18

25

5

95

39

2

Mining

47

13

4

6

12

112

12

3

Total

354

100

72

100

7

90

216

3


*Note: Summary table includes agencies not asked to respond

Percentage of Inquest by Type - 2009.
This image is a pie chart which shows the percentage of inquests by type. 68% Custody, 6% Mining, 1% Discretionary and 25% Construction.

Figure 1 Percentage of Inquests by Type - 2009


Summary – Discretionary Inquests 2009

Inquest Type: Discretionary

 

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

8

3

2009-03

7

Disc

A

4

3

67

1

     

5

               
 

Total

7

   

4

3

67

1

0

0

0

5

0

0

0

0

0

0

0

0

 

 

 

Percentage of Total Response Codes

17

0

0

0

83

0

0

0

0

0

0

0

0

Total number of discretionary inquests: 1

Percentage of Response Codes Discretionary Inquests - 2009.
This image is a bar chart displaying the percentage of response codes for Discretionary Inquests. Response Code: 1 - 17%, 2 - 83%. Response Codes 1A,1B, 1C, 3, 4, 4A, 4B, 5,6,7 and 8 had no response.

Figure 2 Percentage of Response Codes for Discretionary Inquests - 2009.

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
8. Content or intent of recommendation already in place


Summary – Mandatory Custody Inquests 2009

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

8

1

2009-01

0

Cust

A

3

0

n/a

                         

4

2009-04

6

Cust

A

3

3

100

4

1

             

1

     

5

2009-05

3

Cust

H

4

2

50

       

1

       

1

     

6

2009-06

0

Cust

N

1

0

n/a

                         

7

2009-07

0

Cust

S

2

0

n/a

                         

8

2009-08

0

Cust

N

1

0

n/a

                         

10

2009-10

1

Cust

N

1

2

100

                       

2

12

2009-12

4

Cust

A

3

1

100

2

     

1

             

1

13

2009-13

2

Cust

H

1

1

100

1

   

1

                 

14

2009-14

5

Cust

A

3

5

60

1

             

1

     

5

15

2009-15

0

Cust

N

5

0

n/a

                         

16

2009-16

2

Cust

N

2

2

0

                         

17

2009-17

5

Cust

H

3

7

71

2

     

1

       

3

   

1

19

2009-19

35

Cust

H

10

8

112

2

6

1

 

6

       

5

   

18

20

2009-20

0

Cust

N

1

0

n/a

                         

21

2009-21

7

Cust

S

2

4

50

1

     

1

             

6

22

2009-22

6

Cust

N

2

1

100

           

1

         

5

23

2009-23

1

Cust

A

3

1

100

1

                       

24

2009-24

0

Cust

U

4

0

n/a

                         

25

2009-25

6

Cust

S

2

1

100

 

1

   

1

 

1

         

2

26

2009-26

0

Cust

N

2

0

n/a

                         

27

2009-27

86

Cust

A

34

19

53

4

8

2

 

32

       

8

   

13

28

2009-28

0

Cust

N

1

0

n/a

                         

30

2009-30

0

Cust

N

4

0

n/a

                         

32

2009-32

4

Cust

S

1

1

100

4

                       

34

2009-34

0

Cust

S

2

0

n/a

                         

38

2009-38

0

Cust

N

1

0

n/a

                         

39

2009-39

7

Cust

A

8

6

67

1

2

             

3

   

1

41

2009-41

1

Cust

H

3

2

50

                 

1

     

42

2009-42

5

Cust

H

1

1

100

                       

5

43

2009-43

1

Cust

N

1

2

100

                       

2

44

2009-44

0

Cust

N

1

0

n/a

                         

45

2009-45

0

Cust

N

1

0

n/a

                         

46

2009-46

10

Cust

N

7

3

100

4

2

2

           

1

   

4

47

2009-47

2

Cust

S

3

1

100

2

                     

1

50

2009-50

0

Cust

H

6

0

n/a

                         

51

2009-51

0

Cust

N

1

0

n/a

                         

52

2009-52

8

Cust

S

8

4

75

3

1

1

 

1

1

1

         

2

53

2009-53

3

Cust

N

1

1

100

           

2

1

         

54

2009-54

0

Cust

A

2

0

n/a

                         

56

2009-56

0

Cust

N

1

0

n/a

                         

57

2009-57

0

Cust

N

1

0

n/a

                         

59

2009-59

1

Cust

N

2

1

100

                       

1

60

2009-60

0

Cust

S

2

0

n/a

                         

62

2009-62

0

Cust

N

2

0

n/a

                         

65

2009-65

7

Cust

N

3

1

100

5

2

                     

67

2009-67

0

Cust

H

2

0

n/a

                         

68

2009-68

0

Cust

H

3

0

n/a

                         

70

2009-70

0

Cust

N

1

0

n/a

                         
 

Total

218

   

161

80

83.5

37

23

6

1

44

1

5

1

1

23

0

0

69

 

 

 

Percentage of Total Response Codes

17

11

3

.5

21

.5

2

.5

.5

11

0

0

33

Total number of Mandatory Custody Inquests: 49

Percentage of Response Codes Mandatory Custody Construction Inquests - 2009.
This image is a bar chart which displays the percentage of Mandatory Custody Inquest response code.
Response code: 1 - 17%, 1A - 11%, 1B - 3%, 1C - 0.5%, 2 - 21%, 3 - 0.5%, 4 - 2%, 4A - 0.5%, 4B - 0.5%, 5 - 11%, and 8 - 33%. Response codes 6 and 7 had no response.

Figure 3 Percentage of Response Codes for Mandatory Custody Inquests – 2009.

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
8. Content or intent of recommendation already in place


Summary – Mandatory Construction Inquests 2009

 

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

8

2

2009-02

1

Const

A

2

1

100

   

1

                   

9

2009-09

1

Const

A

1

1

100

                       

1

18

2009-18

11

Const

A

3

1

100

1

                     

10

29

2009-29

10

Const

A

2

6

50

2

     

1

       

4

   

5

31

2009-31

2

Const

A

1

4

75

 

2

             

1

   

1

33

2009-33

4

Const

A

1

2

100

                       

5

35

2009-35

10

Const

A

5

5

80

       

2

       

2

   

6

36

2009-36

3

Const

A

2

1

100

                       

3

37

2009-37

2

Const

A

3

1

100

                       

2

48

2009-48

0

Const

A

3

0

n/a

                         

49

2009-49

6

Const

A

2

1

100

                       

6

55

2009-55

6

Const

A

2

1

100

                 

1

   

5

58

2009-58

9

Const

A

2

3

67

1

3

                   

1

61

2009-61

1

Const

A

2

2

50

                       

1

64

2009-64

2

Const

A

2

1

100

                       

2

66

2009-66

0

Const

A

1

0

n/a

                         

71

2009-71

8

Const

A

3

3

100

5

1

1

2

2

             

6

72

2009-72

6

Const

A

2

1

200

2

       

1

           

4

 

Total

82

   

39

34

95

11

6

2

2

5

1

0

0

0

8

0

0

58

 

 

 

Percentage of Total Response Codes

12

7

2

2

6

1

0

0

0

9

0

0

62

Total number of Mandatory Construction Inquests: 18

Percentage of Response Codes Mandatory Construction Inquests – 2009. 
This image is a bar chart which displays the percentage of response codes for mandatory construction inquests.
Response Code: 1-12%, 1A-7%, 1B-2%, 1C-2%, 2-6%, 3-1%, 5-9%, and 8-62%
Response codes 4, 4A, 4B, 6 and 7 had no response.

Figure 4 Percentage of Response Codes for Mandatory Construction Inquests - 2009.

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
8. Content or intent of recommendation already in place


Summary – Mandatory Mining Inquests 2009

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

8

11

2009-11

7

Mining

A

3

2

100

 

2

             

5

   

11

40

2009-40

13

Mining

A

2

4

50

       

3

       

1

   

5

63

2009-63

5

Mining

A

2

1

200

 

1

   

1

             

4

69

2009-69

22

Mining

A

5

5

100

 

3

   

2

1

           

10

 

Total

47

   

12

12

112.5

0

6

0

0

6

1

0

0

0

6

0

0

30

 

 

 

Percentage of Total Response Codes

0

12

0

0

12

2

0

0

0

12

0

0

61

Total number of Mandatory Mining Inquests: 4

Percentage of Response Codes Mandatory Mining Inquests – 2009. 
This image is a bar chart which displays the percentage of response codes for mandatory mining inquests.
Response Code: A-12%, 2-12%, 3-2%, 5-12%, 8-61%.
Response codes 1, 1B, 1C, 4, 4A, 4B, 6 and 7 had no response.

Figure 5 Percentage of Response Codes for Mandatory Mining Inquests – 2009.

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
8. Content or intent of recommendation already in place


Summary of Inquests – 2009

Average Number of Recommendations Inquest Type – 2009. This image is a bar chart which displays the average number of recommendations by inquest type.
Construction-5, Custody-4, Mining-12, and Discretionary-7.

Figure 6 Average Number of Recommendations, Inquest Type, 2009.

Percentage of Total Recommendations, Inquest Type – 2009. This image is a pie chart which displays the percentage of total recommendations by type of inquest.
Custody-62%, Mining-13%, Discretionary-2% and Construction-23%.

Figure 7 Percentage of Total Recommendations, Inquest Type, 2009.

Average Number of Days Per Inquest.
This image is a bar chart which displays the average number of days per inquest. Discretionary-4, Custody-3, Construction-2, and Mining 3.

Figure 8 Average Number of Days per Inquest 2009.

Average Response Rate, Inquest Type – 2009. This image is a bar chart which displays the average response rate by type of inquest.
Discretionary-67%, Custody-79%, Construction-88%, and Mining-83%.

Figure 9 Average Response Rate, Inquest Type, 2009.


Comparison of Inquest Type and Manner of Death for 2009 Inquests

Inquest Type

Manner of Death (By What Means)

 

 

Natural

Accident

Suicide

Homicide

Undetermined

Total

Discretionary

0

1

0

0

0

1

Custody

23

8

8

9

1

49

Construction

0

18

0

0

0

18

Mining

0

4

0

0

0

4

Total

23

31

8

9

1

72

 

 

 

 

 

 

 

% of Total

32

43

11

13

1

100

Comparison of Inquest Type and Manner of Death – 2009.
This image is a bar chart which displays a comparison of the type of inquest and the manner of death.
Discretionary: N=0, A=1, S=0, H=0, U=0
Custody: N=23, A=8, S=8, H=9, U=1
Construction: N=0, A=18, S=0, H=0, U=0
Mining: N=0, A=4, S=0, H=0, U=0
Total: N=23, A=31, S=8, H=9, U=1

Figure 10 Comparison of Inquest Type and Manner of Death, 2009.

Percentage of Inquests, Manner of Death – 2009. This image is a pie chart which displays the percentage of inquests by manner of death.
Accident-43%, Suicide-11%, Homicide-13%, Undetermined-1%, Natural-32%.

Figure 11 Percentage of Inquests, Manner of Death, 2009.


2009 Inquests With No Recommendations

 

Inquest Number

Inquest Type

By What Means

# Orgs. Asked To Respond

1

2009-1

Cust

A

0

6

2009-6

Cust

N

0

7

2009-7

Cust

S

0

8

2009-8

Cust

N

0

15

2009-15

Cust

N

0

20

2009-20

Cust

N

0

24

2009-24

Cust

U

0

26

2009-26

Cust

N

0

28

2009-28

Cust

N

0

30

2009-30

Cust

N

0

34

2009-34

Cust

S

0

38

2009-38

Cust

N

0

44

2009-44

Cust

N

0

45

2009-45

Cust

N

0

48

2009-48

Const

A

0

50

2009-50

Cust

H

0

51

2009-51

Cust

N

0

54

2009-54

Cust

A

0

56

2009-56

Cust

N

0

57

2009-57

Cust

N

0

60

2009-60

Cust

S

0

62

2009-62

Cust

N

0

66

2009-66

Const

A

0

67

2009-67

Cust

H

0

68

2009-68

Cust

H

0

70

2009-70

Cust

N

0

Total number of inquests with no recommendations: 26

% of total inquests in 2009 with no recommendations: 36%


Manner of Death for Inquests with No Recommendations

 

By What Means

 
 

Natural

Accident

Suicide

Homicide

Undetermined

TOTAL

Inquest Type

           

Custody

15

2

3

3

1

24

Construction

0

2

0

0

0

2


Historical Analysis of Inquests 2003-2009

 

2003

2004

2005

2006

2007

2008

2009

Total Number of Inquests

74

57

80

53

59

76

72

Number of Construction Inquests (Mandatory)

20

12

23

14

16

17

18

Number of Custody Inquests (Mandatory)

41

29

39

35

35

54

49

Number of Mining Inquests (Mandatory)

6

5

3

1

4

2

4

Total Number of Mandatory Inquests

67

46

65

50

55

73

71

Total number of Discretionary Inquests

7

11

15

3

4

3

1

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

Total Number of Inquests Per Year (2003 – 2009). This image is a bar chart which displays the total number of inquests per year from 2003 to 2009.
2003-74, 2004-57, 2005-80, 2006-53, 2007-59, 2008-76, 2009-72.

Figure 12 Total Number of Inquest Per Year, 2003 - 2009.

Number of Discretionary Inquests (2003 – 2009). This image is a bar chart which displays the number of Discretionary inquests from 2003 to 2009.
2003-7, 2004-11, 2005-15, 2006-3, 2007-4, 2008-3, 2009-1.

Figure 13 Number of Discretionary Inquests, 2003 - 2009.

Number of Mandatory Custody Inquests (2003 – 2009). This image is a bar chart which displays the number of mandatory custody inquests from 2003 to 2009.
2003-67, 2004-46, 2005-65, 2006-50, 2007-55, 2008-73, 2009-71.

Figure 14 Number of Mandatory Custody Inquests, 2003 - 2009.

Number of Mandatory Construction Inquests (2003 – 2009). This image is a bar chart which displays the number of mandatory construction inquests from 2003 to 2009.
2003-20, 2004-12, 2005-23, 2006-14, 2007-16, 2008-17, 2009-18.

Figure 15 Number of Mandatory Construction Inquests, 2003 – 2009.

Number of Mandatory Mining Inquests (2003 – 2009). This image is a bar chart which displays the number of mandatory mining inquests from 2003 to 2009.
2003-6, 2004-5, 2005-3, 2006-1, 2007-4, 2008-2, 2009-4.

Figure 16 Number of Mandatory Mining Inquests, 2003 – 2009.


Historical Analysis: Police Custody

Inquests - Police Custody 2004 to 2009. This image is a bar chart which displays the number of inquests and corresponding number of recommendations from 2004 to 2009 involving police custody.
2004 4 inquests – 22 recommendations
2005 10 inquests – 72 recommendations
2006 8 inquests – 45 recommendations
2007 7 inquests – 56 recommendations
2008 19 inquests – 114 recommendations
2009 18 inquests – 170 recommendations

Figure 17 Inquests - Police Custody 2004 – 2009. Number of Recommendations.

Number of Recommendations by Manner of Death

 
             

 

2004

2005

2006

2007

2008

2009

Natural

0

8

4

0

37

11

Accident

0

48

2

20

41

105

Homicide

20

0

12

14

35

44

Suicide

2

16

5

0

1

10

Undetermined

0

0

22

22

0

0

Inquests - Police Custody 2004 to 2009. Number of Recommendations by Manner of Death
This image is a bar chart which displays the number of recommendations for each inquest from 2004 to 2009 categorized by Manner of Death.

 Natural Accident Homicide Suicide Undetermined
2004 0 0 20 2 0
2005 8 48 0 16 0
2006 4 2 12 5 22
2007 0 20 14 0 22
2008 37 41 35 1 0
2009 11 105 44 10 0

Figure 18 Inquests - Police Custody 2004 - 2009. Number of Recommendations By Manner of Death.


Average Number of Recommendations Based on Type of Inquest 2003-2009

 

2003

2004

2005

2006

2007

2008

2009

               

Total number of inquests per year

74

57

80

53

59

76

72

Total number of recommendations per year

379

569

621

190

361

423

354

               

Average number of recommendations per inquest

5.1

10.0

7.8

3.6

6.1

5.6

4.92

Recommendations based on type of Inquest:

             

Number of discretionary inquests

7

11

15

3

4

3

1

Number of recommendations from discretionary inquests

67

226

298

35

101

26

7

Average number of recommendations for discretionary inquests

9.6

20.5

19.9

11.7

25.2

8.7

7

               

Number of mandatory inquests (custody, construction and mining)

54

67

46

50

55

73

71

Number of recommendations from all mandatory inquests

196

312

343

155

260

397

347

Average number of recommendations for all mandatory inquests

3.6

4.7

7.5

3.1

4.7

5.4

5.4

               

Number of mandatory custody inquests

41

29

39

35

35

54

49

Number of recommendations from mandatory custody inquests

151

173

177

117

125

274

218

Average number of recommendations for mandatory custody inquests

3.7

6.0

4.5

3.3

3.6

5.1

4.5

               

Number of mandatory construction inquests

20

12

23

14

16

17

18

Number of recommendations from mandatory construction inquests

151

127

125

32

105

95

82

Average number of recommendations for mandatory construction inquests

7.6

10.6

5.4

2.3

7.5

5.6

4.6

               

Number of mandatory mining inquests

6

5

3

1

4

2

4

Number of recommendations from mandatory mining inquests

33

43

21

6

30

28

47

Average number of recommendations for mandatory mining inquests

5.5

8.6

7.0

7.0

7.5

14

11.8

Total Number of Recommendations, 2003– 2009. This image is a bar chart which displays the total number of recommendations for each year from 2003 to 2009.
2003-379, 2004-569, 2005-621,2006-190, 2007-361, 2008-423, 2009-354.

Figure 19 Total Number of Recommendations, 2003 - 2009.

Average Number of Recommendations Per Inquest, 2003 – 2009. This image is a bar chart which displays the average number of recommendations per inquest per year from 2003 to 2009.
2003-5.1, 2004-10, 2005-7.8, 2006-3.6, 2007-6.1, 2008-5.6, 2009-4.9.

Figure 20 Average Number of Recommendation Per Inquest, 2003 – 2009.

Average Number of Recommendations Per Inquest, Discretionary Inquests, 2003 – 2009. This image is a bar chart which displays the average number of recommendations per Discretionary inquest from 2003 to 2009.
2003-9.6, 2004-20.5, 2005-19.9, 2006-11.7, 2007-25.2, 2008-8.7, 2009-7.

Figure 21 Average Number of Recommendations Per Inquest, Discretionary Inquests, 2003 – 2009.

Average Number of Recommendations Per Inquest, Custody inquests, 2003 – 2009. This image is a bar chart which displays the average number of recommendations per Custody inquest from 2002 to 2008.
2003-3.7, 2004-6, 2005-4.5, 2006-3.3, 2007-3.6, 2008-5.1, 2009-4.4

Figure 22 Average Number of Recommendations Per Inquest, Custody Inquests, 2003 – 2009.

Average Number of Recommendations Per Inquest, Construction inquests, 2003 – 2009.
This image is a bar chart which displays the average number of recommendations per Construction inquest from 2003 to 2009.
2003-7.6, 2004-10.6, 2005-5.4, 2006-2.3, 2007-7.5, 2008-5.6, 2009-4.6.

Figure 23 Average Number of Recommendations Per Inquest, Construction Inquests, 2003 – 2009.

Average Number of Recommendations Per Inquests, Mining Inquest, 2003 – 2009. This image is a bar chart which displays the average number of recommendations per Mining inquest from 2003 to 2009.
2003-5.5, 2004-8.6, 2005-7, 2006-7, 2007-7.5, 2008-14, 2009-11.8.

Figure 24 Average Number of Recommendations Per Inquest, Mining Inquests, 2003 – 2009.


Average Number of Days Per Inquest 2003-2009

 

2003

2004

2005

2006

2007

2008

2009

 

             

Total number of inquests per year

74

57

80

53

59

76

72

Total number of days spent in year

237

530

352

220

305

237

216

 

             

Average number of days per inquest

3.2

9.3

4.4

4.2

5.2

3

3

               

Number of discretionary inquests

7

11

15

3

4

3

1

Number of days in discretionary inquests

79

258

142

24

101

15

4

Average number of days for discretionary inquests

11.3

23.5

9.5

8.0

23.5

5

4

 

             

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

67

46

65

50

55

73

71

Number of days for mandatory inquests

158

272

210

195

204

222

212

Average number of days for all mandatory Inquests

2.4

5.9

3.2

3.9

3.7

3

3

 

             

Number of mandatory custody inquests

41

29

39

35

35

54

49

Number of days for mandatory custody inquests

74

164

127

164

136

176

161

Average number of days for custody inquests

1.8

5.7

3.3

4.7

3.8

3

3

 

             

Number of mandatory construction inquests

20

12

23

14

15

17

18

Number of days for mandatory construction inquests

65

94

76

29

57

37

39

Average number of days for construction inquests

3.3

7.8

3.3

2.1

3.5

2

2

 

             

Number of mandatory mining inquests

6

5

3

1

4

2

4

Number of days for mandatory mining inquests

19

14

7

3

11

9

12

Average number of days for mining inquests

3.2

2.8

2.3

3.0

2.7

5

3

Average Number of Days Per Inquest 2003 – 2009. This image is a bar chart which displays the average number of days per inquest from 2003 to 2009.
2003-3.2, 2004-9.3, 2005-4.4, 2006-4.2, 2007-5.2, 2008-3, 2009-3.

Figure 25 Average Number of Days Per Inquest, 2003 – 2009.


Implementation of Recommendations 2003 – 2009

 

2003

2004

2005

2006

2007

2008

2009

Number of recommendations implemented (code 1)

108

(28.5%)

227

(40%)

259

(41.7%)

62

(33%)

125

(39%)

171

(40%)

49

(14%)

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

21

(5.5%)

57

(10%)

39

(6.3%)

12

(12%)

28

(9%)

26

(6%)

35

(10%)

Number of recommendations with alternates implemented (code 1B)

89

(25.3%)

75

(13%)

95

(15.3%)

19

(10%)

31

(10%)

90

(21%)

8

(2%)

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

11

(2.9%)

14

(2.4%)

13

(2.1%)

2

(2%)

10

(3%)

10

(24%)

3

(1%)

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

229

(60.4%)

377

(66%)

406

(65.4%)

108

(56.8%)

194

(60.2%)

297

(70%)

95

(70%)

Discretionary Inquests

41

(18%)

141

(37%)

196

(48%)

14

(48%)

101

(52%)

26

(6%)

1

(0.3%)

Mandatory Inquests (total)

186

(81%)

236

(63%)

210

(52%)

211

(58%)

126

(65%)

397

(94%)

94

(28%)

Custody

58

(25%)

124

(33%)

111

(27%)

82

(43%)

74

(38%)

274

(65%)

67

(19%)

Construction

101

(44%)

84

(22%)

87

(22%)

12

(6%)

47

(24%)

95

(22%)

21

(6%)

Mining

27

(12%)

28

(7%)

12

(3%)

17

(8.9%)

5

(3%)

28

(7%)

6

(2%)

Number of recommendations under consideration (Code 2)

42

(11.1%)

92

(16%)

81

(13%)

32

(16.8%)

66

(18.2%)

45

(11%)

60

(17%)

Number of recommendations with unresolved issues (Code 3)

9

(2.4%)

9

(2.4%)

13

(2.1%)

0

(0%)

5

(1.4%)

2

(0.5%)

3

(0.8%)

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

18

(4.7%)

23

(4%)

27

(4.3%)

5

(2.63%)

17

(4.7%)

13

(3%)

5

(1%)

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

3

(0.8%)

4

(0.7%)

12

(1.9%)

3

(1.57%)

13

(3.6%)

5

(1%)

1

(0.2%)

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

0

(0%)

0

(0%)

0

(0%)

0

(0%)

0

(0%)

2

(0.5%)

1

(0.2%)

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

16

(4.2%)

22

(3.9%)

45

(7.2%)

17

(8.9%)

35

(9.7%)

42

(10%)

37

(10%)

Number of recommendations that did not respond (Code 6)

34

(9%)

34

(6%)

30

(4.8%)

21

(11%)

27

(7.5%)

52

(12%)

0

(0%)

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

28

(7.4%)

10

(1.8%)

7

(1.1%)

4

(2.1%)

4

(1.1%)

4

(1%)

0

(0%)

Content or intent of recommendation already in place (Code 8)*

           

157

(44%)

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.

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

* An additional new code was implemented in 2009 to reflect that the intent of the recommendation is already in place.


Inquests With No Recommendations 2003 - 2009

 

2003

2004

2005

2006

2007

2008

2009

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

26

(35%)

9

(16%)

14

(17.5%)

19

(35.8%)

14

(24%)

21

(27%)

26

(36%)

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

1

(3.8%)

0

0

0

0

0

0

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

25

(96.1%)

9

(100%)

14

(100%)

19

(100%)

14

(100%)

21

(100%)

26

(100%)

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

22

(84.6%)

9

(100%)

14

(100%)

15

(78.9%)

11

(78.5%)

19

(90%)

24

(92%)

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

3

(11.5%)

0

0

4

(21%)

3

(21.4%)

2

(10%)

2

(8%)

Mining

0

0

0

0

0

0

0

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

Inquests with No Recommendations 2003-2009. This image is a bar chart which displays the number of inquests by inquest type with no recommendations from 2003 to 2009.
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
2009: Discretionary=0, Custody=24, Construction=2, Mining=0

Figure 26 Inquests With No Recommendations, Inquest Type, 2003 – 2009.

This image is a bar chart which displays the total number and percentage of total of inquests with no recommendations from 2003 to 2009. 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
2009: Total=26, Percentage=36

Figure 27 Inquests With No Recommendation Total 2003 – 2009.


Rates of Responses to Recommendations 2003 – 2009

2003

2004

2005

2006

2007

2008

2009

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

80.5%

85.9%

76.7%

70.8%

76.3%

75.3%

79.2%

Discretionary Inquests

71.7%

79.4%

79.9%

71%

65%

67%

67%

Mandatory Inquests (total)

83.4%

88%

75.6%*

70.8%

72.6%

78%

83.3%

Custody

74.3%

85.2%

89.5%

95.1%

85%

88%

79%

Construction

81.4%

88.8%

79.1%

88.4%

77%

79%

88%

Mining

94.5%

90%

58.3%

29%

56%

67%

83%

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

             

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

This image is a bar chart which displays the rates of responses to recommendations, mandatory (total) and discretionary inquests, from 2003 to 2009. 
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%
2009: Discretionary=67%, Mandatory=83.3%

Figure 28 Rates of Responses to Recommendations, 2003 – 2009.


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