Ministry of the
Solicitor General

Publications and reports

Office of the Chief Coroner

Publications and reports

Copies of reports not available online can be obtained by contacting the Office of the Chief Coroner at 416-314-4000, 1-877-991-9959 or by email at

July 2021 - Ontario Chief Coroner’s Table on Understanding Fire Deaths in First Nations

April 2021 - Deputy Chief Coroner's Review: COVID-19 Related Deaths of Temporary Foreign Agricultural Workers in 2020

September 2019 - Staying Visible, Staying Connected, For Life: Report of the Expert Panel on Police Officer Deaths by Suicide

October 2018 - Medical Assistance in Dying - Regulations

September 2018 - "Safe With Intervention": The Report of the Expert Panel on the Deaths of Children and Youth in Residential Placements

December 2015 – Winter Sports Death Review Report

April 2015 - Strategic Plan for Ontario’s Death Investigation System, 2015-2020

July 2013 - Review of Ornge Air Ambulance Transport Related Deaths

2011 - Investigation in to the Deaths of Four Residents of a Toronto Retirement Home

2011 - Death Review of the Youth Suicides at the Pikangikum First Nation

2010 – Cycling Death Review

2009 - Drowning Report

Pedestrian Death Review

2015-2019 Office of the Chief Coroner Annual Report

  • 2005-2015 Annual Reports - available on request

Patient Safety Review Committee 2015-2018 Annual Report

2019 Annual Report of the Geriatric and Long Term Care Review Committee

2019 Annual Report of the Maternal and Perinatal Death Review Committee 

2015 Report on Inquests

2017 Report of the Paediatric Death Review Committee and Deaths Under Five Committee

2018 Domestic Violence Death Review Committee Annual Report