The Coroners Office can be used to answer questions surrounding by sdaferv


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                            THE CORONER’S OFFICE

     he Coroner’s Office can be used to answer questions surrounding suspicious or
     unexplained deaths. As a prevention tool, recommendations made following an
     inquest can affect policy and practices in such a way as to prevent future deaths.

  Who are the coroners?

     ll coroners in Ontario are practising physicians appointed by the Lieutenant-Governor.
     They report to the Solicitor-General through the Chief Coroner and they are governed
     by The Coroner’s Act.

 The Investigation

     s mandated by The Coroners’s Act, the coroner investigates all unnatural deaths
     such as those where foul play, suicide, accident, negligence and malpractice are
     suspected. Certain natural deaths are also investigated, such as those occurring
suddenly and unexpectedly or from illness not under treatment by a qualified physician.

Deaths in Nursing Homes, Homes for the Aged, jails, and other institutions must be
notified to a coroner.

  Who calls the coroner?

     rontline workers who believe that a death has occurred under the circumstances set
     out above may notify a coroner. Usually a doctor, a nurse, or a police officer is the
     person who notifies the coroner, but it could be any member of the public.

OAHAI MANUAL                                                       The Coroner’s Office
                                                                         October 1999
                                                                                  Page 2

  The Role of the Coroner

     he investigation should answer five questions surrounding a death:
             1.     Who was the deceased?
             2.     Where did the person die?
             3.     When did the death occur?
             4.     How did the person die? and,
             5.     What were the circumstances surrounding the death?

 The Inquest

      n inquest can be a useful way to clarify the reasons for a death. The findings of a
      inquest can influence policy and procedural change. Who is granted an inquest can
      be a highly political decision.

 What is an inquest?

An inquest is an official inquiry, before a jury, into the cause of a death.

  Reasons for an inquest:

        hen one or more of the questions, “who”, “where”, “when”, “how” and “by what
        means”, cannot be answered:

              <      Death in custody
              <      Death in a mine
              <      Death arising from work in construction

The coroner may also call an inquest to focus public attention on preventable deaths and
to stimulate response by public or private organizations. Some inquests are called to
satisfy the public need to have an open and full hearing of all the facts known about a

OAHAI MANUAL                                                         The Coroner’s Office
                                                                           October 1999
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 The Jury

     here are five jurors chosen from the same jury pool used in the criminal court process.
     Jurors choose a foreman and swear or affirm to “inquire diligently” into the death and
     to make the five findings listed above “without fear or affection, prejudice or partiality
towards any person”. This means that they take an active part in the hearing and are
encouraged to ask questions and raise issues which have not been brought out.

 Who takes part?

      he presiding coroner can allow persons with direct or substantial interest in the
      inquest to take an active part in the proceedings. Lawyers representing these
      ‘persons with standing’ call and question witnesses. Often, the family of the
deceased will have representation, as well, as other groups or persons with a stake in the
verdict. The Coroner is represented by the Crown Attorney.

 The Verdict

      ased on the evidence presented, the jury is instructed to answer the five questions
      and to make any recommendations.

The coroner sends the verdict and recommendations to the Chief Coroner for distribution
to a number of agencies of government, industry, hospitals, etc., which are invited to
respond. The verdict is also available to the public.

It is important to remember that recommendations are not mandatory and the
inquest will not find liability or fault.

OAHAI MANUAL                                                          The Coroner’s Office
                                                                            October 1999
                                                                                    Page 4

                  Coroners’ Offices throughout the Province

         Region              Boundaries             Region                 Boundaries

Central:                 Durham               Northeastern:          Algoma
453 Lansdowne St. E.     Haliburton           19 Monck Road          Cochrane
2nd floor                Halton               Bracebridge P1L IS5    Kenora East of the 87th
Peterborough K9J 6X9     Norhthumberland      Mailing address        Longitude
Mailing address:         Peel                 P.O. Box 10027         Manitoulin
P.O. Box 10009           Peterborough         Bracebridge P1L 1S5    Muskoka
North Monaghan           Victoria             tel: 705-645-9926      Nipissing
Postal Station R.R. #3   York                 fax: 705-645-1694      Parry sound
Peterborough K9J 6X4                                                 Sudbury
tel: 705-745-9887                                                    Temiskaming
fax: 705-748-5055

Eastern:                 Dundas-Glengarry     Northwestern:          Kenora
Beechgrove Complex       Frontenac            189 Red River Road     Kenora West of 87th of
51 Heakes Lane           Hastings             4th Floor              Longitude
Kingston K7M 9B1         Lanark               P.O. Box 4500          Rainy River
tel: 613-531-5737        Leeds-Grenville      Thunder Bay P7B        Thunder Bay
fax: 613-531-5738        Lennox-Addington     6G9
                         Ottawa-Carleton      tel: 807-343-7663
                         Prescott-Russell     fax: 807-343-7665
                         Prince Edward

Toronto:                 Toronto              South Georgian         Bruce
15 Grosvenor Street                           Bay:                   Dufferin
Toronto M4Y 1A9                               125 Delhi Street       Grey
tel: 416-314-4105                             Suite 442              Simcoe
fax: 416-314-3935                             Guelph N1E 4J5         Waterloo
                                              tel: 519-837-6330      Wellington
                                              fax: 519-837-6329

Niagara:                 Brant Haldimand-     Southwestern:          Elgin
301 St. Paul Street      Norfolk              80 Dundas Street       Essex
8th Floor                Hamilton-Wentworth   1st Floor Unit “L”     Huron
St. Catherines L2R 7R2   Niagara              Room 1-068             Kent
tel: 905-682-9209                             London N6A 6A8         Lambton
fax: 905-684-0977                             tel: 519-675-7689      Middlesex
                                              fax: 519-675-7691      Oxford

OAHAI MANUAL                                                        The Coroner’s Office
                                                                          October 1999

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