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New Regulation Strengthens Death Investigation System

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New Regulation Strengthens Death Investigation System

Ministry of the Solicitor General

The province is taking action to increase accountability and transparency in Ontario's death investigation system.

Ontario is amending the General Regulation under the Coroners Act to expand the role of the Death Investigation Oversight Council to allow the council to provide advice and make recommendations to the chief coroner with respect to whether a discretionary inquest is called.

While mandatory inquests are required by law for certain types of deaths, discretionary inquests are called by the chief coroner when it is believed there may be systemic issues that, when explored through an inquest, could advance public safety.

The amended regulation will come into force upon filing.

The change increases accountability in the system by allowing a broader range of perspectives to help determine whether a discretionary inquest should be called. No changes were made to the decision-making authority of the chief coroner. The chief coroner still has legislative authority to direct a coroner to hold an inquest.

Ontario's Death Investigation Oversight Council is the first body of its kind in Canada. The council administers a public complaints process regarding death investigations to help grieving families, and also makes recommendations to the chief coroner, the chief forensic pathologist and the Minister of Community Safety and Correctional Services on matters related to the province's death investigation system.  

Quick Facts

  • The Death Investigation Oversight Council will only provide recommendations on the calling of an inquest when a family appeals the decision of a regional supervising coroner to not hold an inquest.
  • In 2013, Ontario committed to expanding the council’s role based on specific recommendations from the council following a review and assessment of the death investigation system in 2011-12.
  • The Office of the Chief Coroner investigates approximately 16,000 deaths per year across Ontario. Currently, about 6,000 of these cases require an autopsy, performed by a forensic pathologist.

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