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What Do Coroners Do?

By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.

This article originally appeared on page 27 in the April 26-27, 2003 issue of
The Mississauga News under the feature: Health & Wellness, Doctor's Corner.
Dr Peter W Kujtan

You often hear about "the coroner being called in," but most people don't realize what this means. In the Canadian System, coroners are medically trained doctors who are appointed by the Lieutenant-Governor to investigate certain deaths as defined in the Coroner's Act. Their jurisdiction is provincial. In Mississauga, four coroners take turns working seven-day 24-hour shifts. Coroners do not simply pronounce people dead. For a coroner to undertake an investigation, two basic premises must be met. The death must be completely unexpected and sudden. More elderly people are dying at home, the majority of whom die from natural causes, and don't require investigation. At times, the police may ask a coroner's assistance when the person dies without the care of a doctor.

Any person having knowledge of sudden and unexpected death, or death under suspicious circumstances must report to the coroner under law. It is not an act that can be delegated to another. Examples of coroner's investigations include all homicides, suicides, infant deaths, accidents, found human remains and most young people who die unexpectedly. Certain deaths in insitutions and nursing homes must also be reported. The coroner's motto is "We speak for the dead." An investigation is undertaken to determine five essential elements.

A) The identity of the deceased.
B) The date of death.
C) The means of death.
D) The location of death.
E) How the means came to be.

Anyone who dies suddenly cannot be moved without direction from the coroner. One of the first actions in an investigation entails the coroner issuing a warrant to take possession of the deceased. This allows evidence to be preserved, and often removes the burden of difficult decision making from the family, and to next of kin as well. Investigations take time, meaurements, photographs, interviews, evidence collection and more. When the scene is a public place such as a roadway, every effort is made to progress as quickly as possible. Police provide assistance to coroners and vice-versa. The scene and body are under the coroner's jurisdiction, and the coroner may issue warrants for seizure of items directly related to the death, and to enter premises where evidence having direct bearing on the death may be present.

Coroners have the resources of forensic science departments, pathologists and police crime labs available to them. Sometimes the five questions surrounding death cannot easily be answered. When this happens, a warrant for autopsy will be sworn. Not all investigations require an autopsy. In Ontario, all cremations require coroner's certificates to take place.

Coroner investigations do not involve any criminal prosecution, and are not intended to find faults when set policies are ignored. This is a fallacy commonly assumed by the lay public. The role of investigation is largely to protect the public. Coroners examine sensible ways in which needless deaths might be prevented. At times, the investigation requires input from the public by way of jurors, and a public inquest is called. An inquest might examine all the evidence surrounding death, and come up with recommendations, which are forwarded to all concerned parties including the government of the day. Numerous safeguards have been instituted throughout the years by way of the coroner system. These include mandatory seat-belts, bike helmets, smoke detectors and also policy changes in schools and health institutions. Deaths are seldom senseless if lessons can be learned to prevent others. Thanks to coroners, the dead have a chance to utter the last word!

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