Office of the Chief Coroner About the Office

What We Do

What is an autopsy?

An autopsy, sometimes known as a post mortem examination, is a detailed physical examination of a person's remains. It involves examination of the tissues by eye and under a microscope and may include testing for drugs, chemicals or poisons (toxicology) or for infections (microbiology).

What happens after a coroner's investigation?

The coroner's report is filed at the Office of the Chief Coroner. The coroner may make recommendations to persons, agencies or government ministries to make changes that could prevent similar deaths. An inquest may be called in some deaths, but in most cases the coroner determines that an inquest is not necessary to establish the facts of the death, to inform the public or to create recommendations.

What is an inquest?

An inquest is a public hearing held under the authority of the Coroners Act for the purpose of presenting evidence to a jury of five members of the community in which a person died.

After hearing the evidence of and other matters relevant to the circumstances of the death the jury must answer five questions: who was the deceased and how, where, when and by what means did the deceased die.

The jury may also make recommendations based on evidence heard that if implemented might avoid deaths in similar circumstances.

What happens to the jury's verdict and recommendations?

The coroner and the crown attorney will review the verdict and recommendations to ensure that the verdict is "true" (that is, actually based on the evidence heard at the inquest). The jury must not make any finding of legal responsibility or express any conclusion of law on any matter.

The coroner will then read the jury's verdict and recommendations to the inquest court. The coroner will then write a verdict explanation and forward this with the jury's findings to the Chief Coroner of Ontario.

It is one of the responsibilities of the Chief Coroner to distribute the jury's findings to persons, agencies or ministries of government who may be able to implement them. These persons are asked to respond to the recommendations and are advised that their responses are considered public documents available to anyone who requests them.

The staff at the Office of the Chief Coroner will evaluate the responses approximately one year after the recommendations were distributed. The evaluations are based on self-evaluations of the responders.

Recommendations are not mandatory and no one is legally required to respond to the recommendations. However, the strength of the recommendations lies in their practicality and relevance to the issues presented at the inquest. It is rare that a recommendation is made to which no response is received.

What is the motto of the Office of the Chief Coroner?

"We speak for the dead to protect the living".

What is the mission statement of the Office of the Chief Coroner?

"The Office of the Chief Coroner for Ontario serves the living through high quality death investigations and inquests to ensure that no death will be overlooked, concealed or ignored. The findings are used to generate recommendations to help improve public safety and prevent deaths in similar circumstances."