Office of the Chief Coroner About the Office

How Things Are Done

How does a coroner investigate a death?

Usually, a coroner will start by examining the body. The coroner may require the assistance of the police in investigating the circumstances leading to the death. Five questions must be answered:

1. the identity of the deceased; and
2. how;
3. when;
4. where; and
5. by what means

the death occurred. A coroner may decide that there is sufficient information on reasonable medical grounds to answer those questions and an autopsy may not be required.

When the death may have resulted from an accident, suspicious circumstances or foul play, an autopsy is usually conducted. The coroner may discuss this with the family and will be considerate of the family's wishes; however, the coroner decides what is required to fulfill his or her duty under the Coroners Act.

How is an autopsy done?

The body of the deceased person is treated with respect at all times. The pathologist with the assistance of the mortuary staff carries out a detailed external and internal examination of the body. At times there may be health professionals and investigation trainees attending for educational purposes.

Techniques similar to surgical procedures are used. The pathologist removes and examines the major organs of the body, and may take specimens from those organs for further processing and examination under a microscope. In most cases the tissues are returned to the body at the end of the autopsy.

Occasionally, complex cases it may be necessary to retain larger portions of tissue or whole organs for special processing techniques before the examination can be undertaken or for more detailed inspection. Good medical practice requires that, in complex cases, sufficient tissue be retained to allow another pathologist, at another time, to review the specimens and provide additional consultation.

At the end of those examinations the tissues are disposed of as pathological specimens in a manner similar to that used for surgical specimens at hospitals. Sometimes other bodily fluids (such as blood, bile, liver, stomach contents and urine) are sampled and sent for testing. It can take several weeks to get results from these tests.

How long does an autopsy take?

Usually, an autopsy is conducted within 24 hours of death. If the circumstances of the death are complex or involve many investigators (police, labour) the autopsy may be delayed by a day or two. Every attempt is made to not inconvenience the family or to interfere with the religious or cultural practices of the relatives.

A preliminary report on the cause of death may be available after the visual examination; however the final opinion is given only after testing has been completed.

How are the results of the coroner's investigation obtained?

Results of an investigation may be available under the authority of either the Coroners Act or Ontario's Freedom of Information and Protection of Privacy Act. The investigating coroner, the Regional Supervising Coroner or the Office of the Chief Coroner can explain what may be obtained and how to apply for it. For more information, call 416-314-4000.

How is an inquest conducted?

A coroner who has taken special training presides over the inquest, which is open to the public and news media and is usually held in a courtroom or court-like facilities. For the purposes of the inquest, the coroner can administer oaths and issue subpoenas to acquire evidence and to call witnesses who have information that would assist the jury in its duty.

The purpose of an inquest is not to place blame or legal responsibility. Criminal proceedings arising out of a death must be resolved before any inquest can be held. A court reporter records the proceedings and will transcribe the evidence, if requested, for a fee per page.

Anyone interested in participating in the proceedings can apply to the coroner for standing. This may be granted anytime before the end of the proceedings. Counsel or agents may represent persons in this application or they can apply on their own. Application for funding for an inquest can be made to Legal Aid. The Office of the Chief Coroner does not have funding for those participating at an inquest.

Jurors are chosen from the jury roll and swear or affirm to "diligently inquire into the death and determine on the evidence presented at the inquest his/her identity, how, when, where and by what means the deceased came to his or her death and without partiality or bias towards any person, render a true verdict."

The strict rules of evidence do not apply at an inquest but proper courtroom behaviour and protocol are required to protect the importance and integrity of the proceeding. Witnesses are summoned to testify about their knowledge of or involvement in the circumstances of the death. With the assistance of the crown attorney and the coroner, jurors may ask questions of witnesses. Physical evidence may be entered as exhibits for examination. Following the presentation of evidence, parties will be allowed to address the jury and make suggestions about their findings and possible recommendations. The crown attorney will make submissions and then the coroner will charge the members of the jury, reminding them of their oath and advising them of the law as it applies to their verdict.

No one is on trial at an inquest. The presiding coroner and the crown attorney assisting the coroner must protect the goals of the inquest - to bring out the facts relating to the circumstances of the death in a fair and balanced way and allow the jury to make useful and practical recommendations that may prevent similar deaths.