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Coroner’s Inquests: Learn from the Dead to Protect the Living


What is a coroner’s inquest?

An inquest is a public hearing conducted by a coroner before a jury of five members of the impacted community. Inquests are traditionally held for the purpose of informing the public about the circumstances of a death and to gather information to allow the jury to make recommendations to prevent further deaths.

A coroner’s inquest is not a trial. It is meant to be a non-adversarial legal process that seeks to gather evidence and information about a death or series of deaths. Traditionally, a coroner’s inquest is called to answer these five questions:

  1. Who was the deceased?
  2. Where did the death occur?
  3. When did the death occur?
  4. How did the death occur (the medical cause)?
  5. By what means did the death occur (the classification or manner of death)?

In some cases, an inquest involves only a few people, and in other cases, there are many parties, organizations, unions and agencies that are involved in the process. Depending on the circumstances surrounding the death, these questions can be straightforward or systemic and extremely complex.

Large or small, inquests can be an important way to ensure that we learn from the events surrounding a tragedy and make sure that a preventable death never happens again.

When is an inquest called?

There is no time limit within which an inquest must be convened. Sometimes an inquest will be called quickly following a death, and in other cases it takes many years. This is sometimes the case where a criminal or other investigative process is underway.

There are two types of Coroner’s Inquests: mandatory and discretionary.

The Coroners Act establishes certain categories of death that require the Coroner to hold an inquest. These include deaths arising from accidents in certain workplaces, such as construction sites and mining operations, as well as deaths that occurred when the deceased was detained or in custody.

All other inquests are discretionary, which means that the Coroner may convene an inquest if he or she believes that there is a good reason to do so. Some of the factors that the Coroner might consider in deciding whether to convene an inquest include:

  • whether the answers to the five questions above are known;
  • whether there is a need for the public to have an open and full hearing of the circumstances of the death; and
  • whether the Coroner believes there is a need to better understand preventative measures to protect the public.

The spouse, parent, child, brother, sister or personal representative of the deceased may make a written request for an inquest to the investigating coroner, which may impact the coroner’s decision of whether to call one.

The focus of an inquest is usually established by the presiding coroner in a memorandum that sets out the issues that the coroner believes must be addressed. This document is known as the Inquest Brief.

Who can participate in an inquest?

Inquest proceedings are usually led by a Crown attorney who acts as Coroner’s Counsel. The Coroner is the lead party and has responsibility to lay out the facts and evidence of the death or deaths that are the subject of the inquest.

Family members of the deceased, as well as other individuals or organizations with a connection to the inquest, including persons who may be affected by the recommendations, may take an active part in the proceedings. This participation is called “standing.”

Parties with standing may represent themselves or have lawyers or agents represent them at the inquest hearing. Parties may cross-examine witnesses relevant to their expressed interest and may call certain witnesses of their own if the person presiding over the inquest finds that the evidence of such a witness is relevant to the proceedings.

Parties with standing can also present arguments and submissions to the jury after all the evidence has been heard. This is to ensure that every person who might be significantly affected by the verdict or recommendations has an opportunity to be heard and present their point of view.

If necessary, the person presiding over the inquest will hold a separate hearing to determine issues of standing or any other matter that requires a decision in the absence of the jury.

What if I can’t afford a lawyer?

You do not have to retain a lawyer to participate in an inquest. However, inquests, like court proceedings, can be intimidating and complex for members of the public who are not used to participating in legal proceedings.

The Coroner’s Office provides funding to reimburse the cost of participating in an inquest through the Coroner’s Inquest Legal Fee Reimbursement Program. This program provides funding for close family members who meet the following criteria:

  1. a parent or spouse of the deceased;
  2. there are reasonable grounds to believe that the deceased was a victim of crime; and
  3. standing has been granted by the presiding coroner at the inquest into their death.

Applications for funding are made in writing to the Office of the Chief Coroner.

If you believe that the circumstances surrounding a death warrant an inquest, or you are interested in seeking standing to participate in an inquest that has already been called, we can help you consider your options and think about how best to advocate in your situation.