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Strengthening Ontario's death investigation system

Archived Backgrounder

Strengthening Ontario's death investigation system


Ministry of the Solicitor General

Proposed new legislation would, if passed, amend the Coroners Act to improve oversight, accountability and quality assurance within Ontario's death investigation system. The proposed changes respond to recommendations made by the Honourable Justice Stephen Goudge following his Inquiry into Pediatric Forensic Pathology in Ontario.

Key changes under the new legislation would include:


Proposed changes in the legislation would make it easier for the public to understand how the death investigation system works and would make the system itself more accessible, transparent and accountable.
A new death investigation oversight council would be created to oversee the work of the chief coroner and the chief forensic pathologist. This is in response to Commissioner Goudge's recommendations that an independent oversight mechanism be established to oversee Ontario's death investigation system. The council will ensure that the chief coroner and chief forensic pathologist are held accountable for the quality of death investigations in Ontario.

Ontario's Lieutenant Governor would appoint members of the oversight council which would include representatives from the judicial, medical, and government communities and as such would bring specialized expertise to advise and oversee the chief coroner and chief forensic pathologist.


A new complaints committee would be established that would report to the oversight council. The committee would track complaints made about the handling of a particular death investigation or about the conduct of a coroner or pathologist during an investigation.
In general terms, complaints concerning the medical roles of coroners and pathologists would be directed to the College of Physicians and Surgeons, while complaints related to the non-medical roles of coroners and pathologists (e.g., providing evidence in criminal proceedings) would be directed to the chief coroner and chief forensic pathologist respectively.

The committee would ensure the chief coroner and chief forensic pathologist respond to complaints quickly and thoroughly. If a complainant is not satisfied with the response provided by the chief coroner or the chief forensic pathologist, the complaints committee has the authority to review the complaint. The committee would also review any complaints against the chief coroner and the chief forensic pathologist.


In his report, Commissioner Goudge identified the vital role that forensic pathology plays in Ontario's death investigation system. He made several recommendations directed at improving the oversight of forensic pathologists, defining their roles and ensuring quality within the system. These recommendations are addressed in the proposed legislation.

Roles and Responsibilities

The chief forensic pathologist would be established in law as the head of forensic pathology in the province. This would allow him or her to ensure the quality and consistency of services being provided by forensic pathologists across the province. Currently the chief forensic pathologist does not have this legislated responsibility.

Forensic Pathology Service

A new Forensic Pathology Service would be created reporting to the chief forensic pathologist. The new service would bring all of the province's forensic pathology services under one umbrella to ensure consistency, accountability and oversight. Currently, the province's forensic pathology services are decentralized and run by regional forensic pathology units and other hospital facilities where autopsies are performed.

Registry of Pathologists

A registry of pathologists authorized to perform post-mortem examinations would be created and maintained by the chief forensic pathologist. This would ensure that all pathologists providing services in Ontario are appropriately qualified and experienced and have met the strict quality requirement set out by the chief forensic pathologist.

The chief coroner has a responsibility to protect public safety, and needs to be given the clear authority to share information for this purpose. Providing the chief coroner with authority to decide when it is appropriate to share information to advance public safety will help coroners to protect the public by preventing similar deaths. In such cases, the coroner would make every effort to protect privacy by withholding identifying information where possible.

The current legislation allows the coroner to release the results of death investigations only to family members of the deceased, but does not allow the coroner to release the results to other groups or to the public.

In some cases, the coroner has a need to share information when not doing so would put the public at significant risk. For example, if widely used medical equipment were faulty and caused a death, the public would need to be informed.


The intent of the proposed legislation is to build a stronger death investigation system based on the principles of professionalism and accountability. Under such a system, it is the Office of the Chief Coroner who has the expertise and experience needed to determine if an inquest should be held. Decisions on inquests can undergo three levels of review within the Office of the Chief Coroner: local investigating coroner; regional supervising coroner; and the chief coroner.

If the minister made a decision contrary to the chief coroner's, it would be inconsistent with the arm's-length relationship between the Office of the Chief Coroner and government. For this reason, the proposed legislation would remove the power of the Minister of Community Safety and Correctional Services to call an inquest.

The chief coroner's decision regarding an inquest could still be the subject of judicial review, if there was a desire to appeal his or her ruling. Under this proposed change, by removing any potential for political intervention, the final decision is based on science.


All deaths of adult inmates in correctional institutions are, and will continue to be, thoroughly investigated by a coroner who is able to make recommendations to prevent similar deaths. Currently, a coroner must hold an inquest into all such deaths. Where the initial investigation determines that a death in custody was by natural causes, the resulting inquest rarely provides meaningful recommendations to improve public or inmate safety.

Under the new legislation, a death by natural causes in an adult correctional facility would no longer be the subject of a mandatory inquest. A coroner would still be able to call an inquest in such cases if he or she believes an inquest will lead to improvements in public safety.
This change would allow coroners to focus on those complex cases where an inquest could result in meaningful recommendations to make Ontario safer.


All Ontarians deserve high-quality services and that includes death investigations. In his report, Commissioner Goudge recognized that delivering this service is challenging in some areas of the province. The current shortage of doctors in northern, First Nations, and remote communities results in long response times in the event of a death and sometimes coroners are unable to attend a death scene at all.
As recommended by Commissioner Goudge, the new legislation would provide for the appointment of individuals other than medical doctors or police officers to perform coroner's duties. If passed, this amendment will give coroners the flexibility to meet local needs and improve service to northern and remote communities. However, the final decision as to whether or not an inquest is required would continue to rest with the Office of the Chief Coroner.


It is not always clear to the public what the purpose of a death investigation is and this can cause confusion while the investigation is underway. The proposed new legislation would establish in law for the first time the reasons why a death investigation is undertaken.

Each investigation sets out to answer five basic questions about a death:
  • Who died?
  • How did they die?
  • When did they die?
  • Where did they die?
  • By what means did they die?
    The results of an investigation are used to determine whether recommendations are needed to prevent similar deaths or whether the death requires the additional public scrutiny of 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 and other matters relevant to the circumstances of the death, the jury must answer the above five questions. They also may make recommendations based on evidence heard that if implemented, might avoid deaths in similar circumstances.



Law and Safety