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Coroners Investigate Suspicious Deaths

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

Article printed on page 24 in the January 22, 2014 issue of
The Mississauga News under the feature: Health & Beauty, Medicine Matters.

Dr. Peter W. Kujtan

Coroners are medically trained doctors who are appointed by the Lieutenant-Governor to investigate certain deaths. Their jurisdiction is provincial, and governed by the Coroners Act. Most deaths do not require Coroners to investigate or make a pronouncement. 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 expected 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 Coroners investigations include all homicides, suicides, infant deaths, accidents, found human remains and most young people who die unexpectedly. Certain deaths in institutions 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:
1. The identity of the deceased.
2. The date of death.
3. The means of death.
4. The location of death.
5. How the means came to be.

Anyone dying suddenly cannot be moved without a Coroner's direction. Investigations begin with 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 in fact can protect the privacy of the next of kin as well.

Investigations take time, measurements, 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 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 be easily answered. When this happens, a warrant for autopsy will be issued. Not all investigations require an autopsy. In Ontario, all cremations require a Coroner's review.

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 recently deceased have a chance to utter the last word!


Related resources:

Coroner from Wikipedia.

Crowner: Origins of the Office of Coroner by Prof. Bernard Knight, CBE. From Britannia History.

Common Questions About Death Investigations. From Ontario Ministry of Community Safety and Correctional Services. "Ontario is a diverse province, and the Coroners' Office respects the many different religious and philosophical views of Ontarians concerning death." This site answers many questions relating to the sudden, unexpected or suspicious death of an individual, including: Who is a coroner and what is the coroner's job? What is a death investigation? How are the police involved in a death investigation? Why is a coroner called? What is a reportable death? Who calls the coroner? What is an autopsy? Who decides if an autopsy is done? ... it is important to understand that the coroner's decision for autopsy is final and legally binding. Who performs the autopsy? What happens to the body? Can organs/tissues be donated after death? What is an inquest? What happens during an inquest? How do family members obtain information/reports? How to get a death certificate? The coroner creates an original copy of the Medical Certificate of Death and sends it to the office of the Registrar General. Only the Registrar General can issue a copy of the death certificate.

Coroners Act - Ontario.

Office of the Chief Medical Examiner: Role of the Medical Examiner's Office from Justice and Solicitor General in Alberta. "When a death occurs suddenly or cannot be explained, the Office of the Chief Medical Examiner conducts an investigation. All such deaths in Alberta are investigated under the authority of the Fatality Inquiries Act."

Fatality Inquiries Act - Alberta.

The Role of the Coroner in B.C. The sudden and unexpected death of someone close to you can raise many questions. It is the responsibility of the BC Coroners Service to confirm the identity of the deceased and investigate the circumstances of the death - the how, when, where and by what means. From British Columbia Ministry of Public Safety and Solicitor General.

Family Justice: The Role of the Chief Medical Examiner's Office from Manitoba Justice.

The Fatality Inquiries Act - Manitoba.

Canadian Coroner and Medical Examiner Database (CCMED) from Statistics Canada. "The Canadian Coroner and Medical Examiner Database (CCMED), by storing information on deaths reported to Coroners and Medical Examiners (C/MES), will facilitate the identification and characterization of emerging and known safety hazards with the aim of contributing to a decrease in preventable deaths among Canadians."

Canadian Coroner and Medical Examiner Annual Report. from Statistics Canada. "The coroners and medical examiners in the nine provinces and territories currently covered by the Canadian Coroner and Medical Examiner Database investigated 98,623 deaths that occurred in the period 2006 to 2008 ... In general, male decedents accounted for almost two thirds of coroner and medical examiner caseload. Investigations involving males age 50 to 69 represented the greatest share of coroner or medical examiner cases in all provinces and territories except New Brunswick and Ontario, where males aged 70 to 89 represented the greatest share of coroner caseload ..."

Hospital Related Deaths: The Role of the Coroner's Office in Enhancing Patient Safety. Hospital Related Deaths: The Role of the Coroner's Office in Enhancing Patient Safety PowerPoint Presentation by Dr. Dan Cass, MD FRCPC. Learning Objectives: 1. The role of the death investigation system in examining and preventing medically-related deaths. 2. The importance of close collaboration between health care providers, hospitals and coroners in medical death investigations. 3. Ways in which the death investigation system can help enhance patient safety.

What Does a Coroner Investigator Do? From wiseGEEK. "A coroner investigator is a law enforcement officer who works with a team of people to determine the cause of death in situations where a death is deemed suspicious. Coroner investigators work under the supervision of a coroner, also known as a medical examiner. People can enter this law enforcement profession from a number of different angles, including experience in the medical profession, experience as a law enforcement officer, or training in criminal justice."

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