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Ontario Acts On Goudge Recommendations

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Ontario Acts On Goudge Recommendations

McGuinty Government Commits To A Stronger, More Accountable Coroners System

Ontario's death investigation system would be stronger, more accountable and provide for greater oversight and transparency under proposed legislation introduced by Community Safety and Correctional Services Minister Rick Bartolucci today. Highlights of the bill include a new oversight council, complaints committee and a provincial forensic pathology service.

The proposed legislation addresses all the recommended legislative amendments in the report of the Honourable Justice Stephen Goudge's Inquiry into Pediatric Forensic Pathology in Ontario. This includes amendments to the Coroners Act that would establish a framework to strengthen the death investigation system in Ontario.
The new death investigation oversight council, made up of experts from the medical, legal and government communities, would oversee the work of the chief coroner and chief forensic pathologist to ensure the quality of the system.
The Ontario Forensic Pathology Service recognizes the complex and important role forensic pathology plays in death investigations. The new service will centralize forensic pathology under the chief forensic pathologist, ensuring consistent, high-quality standards for forensic pathology across the province.

Other key provisions of the legislation include:
  • A registry of pathologists approved to conduct autopsies in Ontario
  • An improved complaints system overseen by the oversight council
  • Improved services to northern, First Nations and remote communities.

Quick Facts

  • Ontario's coroners investigate approximately 20,000 deaths every year.
  • Approximately 7,000 of those investigations require a post-mortem examination by a pathologist.
  • The Coroners Act has not been significantly updated since the 1970s.

Background Information

Additional Resources


“Commissioner Goudge gave us the roadmap to a stronger more accountable death investigation system. This legislation takes us a long way down that road. If passed, it would ensure we have the checks and balances in place to prevent a similar tragedy in the future.”

Rick Bartolucci

Minister of Community Safety and Correctional Services

“This legislation would provide us the framework we need to truly revitalize the system, and to help us build on the work we've already done to earn back the trust of the people of Ontario.”

Dr. Andrew McCallum

Chief Coroner, Ontario

“By recognizing the importance of a professional forensic pathology service, this legislation would help us to take the next step towards delivering the consistent high quality service the people of Ontario deserve.”

Dr. Michael Pollanen

Chief Forensic Pathologist, Ontario



Law and Safety