Ontario Newsroom

Ontario's Death Investigation System

Archived Backgrounder

Ontario's Death Investigation System


Ministry of the Solicitor General

The Office of the Chief Coroner for Ontario performs 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.

Ontario's coroners are physicians trained to investigate sudden and unexpected deaths, as well as deaths in circumstances requiring further examination. The purpose of these investigations is to answer five questions:

  • Who died?
  • How did they die?
  • When did they die?
  • Where did they die?
  • By what means did they die?

Coroners also determine whether a death warrants an inquest - a public hearing during which evidence is presented to a jury of members of the community in which a person died. The jury must answer the five questions and may also make recommendations to avoid deaths in similar circumstances. Approximately 75 inquests are held each year.

Each year in Ontario, there are approximately 80,000 deaths. The province's coroners investigate 20,000 deaths per year, 250 of which involve pediatric deaths (under the age of five).

Ontario has more than 300 coroners. Of these, 65 are also qualified to conduct inquests.


Pathologists are physicians trained in the examination of body tissues and the impact of disease on tissues and organs. Forensic pathologists have additional training in matters likely to be presented to the courts. Pediatric forensic pathology is a particular sub-specialty of pathology focusing on complex cases involving the death of young children.

Pathologists conduct autopsies when warranted by a coroner, who decides what is required under the Coroners Act. Autopsies are usually conducted when a death may have resulted from an accident, foul play or criminally suspicious circumstances. Each year, coroners warrant more than 7,000 autopsies conducted by pathologists. Of these, between 200 and 250 involve criminally suspicious deaths or homicides.

Ontario's chief forensic pathologist reports to the chief coroner and is responsible for establishing guidelines for the conduct of forensic pathology in the province.


The Office of the Chief Coroner for Ontario has made many operational and management improvements to strengthen the death investigation system and ensure quality.

New Standards
  • Protocol for investigating pediatric deaths The Office of the Chief Coroner has implemented a protocol for coroners, pathologists, police and other members of the death investigation team to follow when examining pediatric deaths under two years of age. Since 2006, all deaths of children under the age of five years are now subjected to this standardized investigation.
  • Standardized peer review process Since 2004, all forensic autopsies on criminally suspicious cases, homicides and cases going to inquest undergo a peer review process. This process helps to ensure that all key examinations are performed, and that the facts and conclusions emerging from the exams are logical and clearly supported by materials available for any independent review.
  • Autopsy and death investigation guidelines Under the direction of the chief forensic pathologist, new guidelines have been prepared for autopsies on all criminally suspicious and homicide cases. The guidelines include instructions and information specific to pediatric autopsies. These guidelines also focus on the important observations to make at death scenes, what should be included in reports and how information should be presented, as well as the essential communication expected among pathologists and other members of the death investigation team.
  • Early case conferences Since 2002, members of a death investigation team hold early case conferences following all homicides or criminally suspicious cases where there are outstanding issues or significant unanswered questions. The conferences include a senior coroner, the pathologist who conducted the examination, scientists from the Centre of Forensic Sciences, police and any other appropriate experts. The conference ensures that members of the investigative team know the findings of an autopsy and provides them an opportunity to identify any outstanding examinations necessary before a pathologist can reach conclusions.
Ensuring Expertise
  • Expert pediatric autopsies Since 2002, pediatric autopsies are conducted in four centres (London, Ottawa, Hamilton and Toronto). This ensures that the complex autopsies are conducted at centres where resources and pathology and pediatric expertise are greatest.
  • Professional training for pathologists A special new course emphasizing the importance of fair and balanced testimony has been developed for pathologists who provide expert testimony in court.
Quality Assurance
  • Coroner's reviews The Chief Coroner's Review Process allows the chief coroner to appoint a panel to review the work of a coroner should serious concerns be raised about that work. As well, child deaths are the exclusive focus of two new expert committees in the chief coroner's office. They are the Deaths Under Five Committee, which reviews the deaths of all children under five and the Pediatric Death Review Committee, which reviews complex cases where children of any age have died.

  • Management and operational review In the fall of 2007, the Office of the Chief Coroner engaged an external consulting firm to review its quality assurance processes and practices in the areas of strategic planning, human resources, leadership and support and internal communication. The review was submitted to the Goudge Inquiry, and the chief coroner's office is in the process of acting on its recommendations.
 Resources and Infrastructure
  • Increased funding
 The government has nearly doubled annual funding to the Office of the Chief Coroner from approximately $20 million in 2003-04 to more than $36 million in 2008-09. The additional funds have been used to improve remuneration for investigating coroners and pathologists, as well as to meet other increases in the operational costs of the chief coroner's office.
  • A new Forensic Services Complex
The ministry is in the planning stages of a new Forensic Services Complex that could put the Office of the Chief Coroner and the Centre of Forensic Sciences on one site. The proposed complex would provide the space and advanced technology to support a growing population and keep pace with the demands of the justice sector.

  • Central dispatch for coroners
A three-month pilot program to evaluate the effectiveness of a central dispatch system will begin in Halton Region this fall. This initiative addresses the need for proper communication among regional supervising coroners and investigating coroners so that regional offices are aware of all active cases within their jurisdiction.


As well as the improvements made by the chief coroner's office, the Ministry of the Attorney General has also implemented a number of initiatives to improve the way it handles child homicide cases, including:
  • Appointing a nine-person Child Homicide Resource Team to provide advice to Crowns at all stages of a child homicide prosecution.
  • Developing a database to better track child homicide cases and the pathologists involved in those cases.
  • Enhancing Crown training and education on pediatric forensic pathology issues and assessing expert evidence.

The Ministry of the Attorney General has retained the Honourable Patrick LeSage, former chief justice of the Superior Court of Justice, to advise the Criminal Convictions Review Committee. Mr. LeSage and the committee provide advice to Crowns on trends emerging from child homicide cases and other cases.



Law and Safety