Coroner Guest Lecture

Question 1

How many deaths were there in ON in 2023, and how many were investigated by the office of the coroner?

Answer 1

121,000 deaths
21,000 investigated

Question 2

What is the vision and mission of the office of the coroner?

Answer 2

High-quality death investigations for a safer and healthier ON

Question 3

Give examples of some of the objectives of the office of the chief coroner.

Answer 3

Case-centered approach
Commit individually to ensuring quality work as a team to transform the organization
Produce consistent, high quality, useful outputs

Question 4

What percentage of Ontarians choose cremation?

Answer 4

70-80%

Question 5

How many people die of drug-related deaths daily in ON?

Answer 5

~7-8 people

Question 6

What five questions must be answered when someone dies?

Answer 6

Who
When
Where
How
Manner of death

Question 7

Give examples of scientific methods of identifying a deceased. (4)

Answer 7

DNA
Dental records
Medical imaging
Fingerprints

Question 8

List the expectations of investigating coroners in the performance of their duties. (7)

Answer 8

Knowledge
Communication
Trust
Teamwork
Accountability
Attention to results
Behaviour

Question 9

List some values of the Office of the Chief Coroner.

Answer 9

Integrity
Responsiveness
Embrace opportunities, change, innovation
Strive toward best practice and best quality
Diversity

Question 10

Describe the governance of the OFPS and OCC

Answer 10

Part of Ministry of Solicitor General, accountable to minister

Question 11

List some QA methods for the OCC, OFPS.

Answer 11

Thorough scene investigation
Comprehensive autopsy
Interdisciplinary collaboration
Family engagement
Training and education
Learning points from other jurisdictions

Question 12

List some complexities in Coronal death investigations.

Answer 12

Investigators may lack necessary training, knowledge
Insufficient resources
Poor communication
Failure to secure scene
Inaccurate autopsy/coronial reports
Bias or preconceived notions
Lack of follow-up investigation
Legal challenges
Victim ID issues
Public pressure and media influence

Question 13

What death investigation system does ON have>

Answer 13

Coroner

Question 14

List the team members of a death investigation. (7)

Answer 14

Public health
Police
Coroner
Forensic pathologist
Forensic scientists
Consultants
Other agencies

Question 15

Outline the OCC structure.

Answer 15

Chief coroner
3 Deputy chief coroners
Regional supervising coroners

Question 16

What are the 5 steps of an autopsy/death investigation?

Answer 16

Scene
External
Internal
Special tests
Reports

Question 17

Outline coroners act s. 10

Answer 17

Every person who has reason to believe that a deceased person died…
As a result of violence, misadventure, negligence, misconduct, malpractice
By unfair means
During or following pregnancy, latter in circumstances that might be attributable thereto
Suddenly and unexpectedly
From any cause other than disease
Under such circumstances as may require investigation
From disease or sickness for which he was not treated by a legally qualified medical practiitoner

Question 18

What are the powers of the coroner? (6)

Answer 18

Take possession of any dead body
Enter and inspect any place a dead body is or removed from
Inspect any place a deceased person was prior to death
Inspect and extract info from records or writings relating to the deceased or his circumstances and make copies
Order autopsies by warrant
Order ancillary testing of bodily fluids

Question 19

What is a Category A forensic pathologist?

Answer 19

Investigates all types of cases

Question 20

What is a Category B forensic pathologist?

Answer 20

Investigates only criminally non-suspicious adults

Question 21

What is a Category C forensic pathologist?

Answer 21

Investigates only criminally non-suspicious children

Question 22

How many jurors are there in an inquest?

Answer 22

5

Question 23

When is an inquest mandatory?

Answer 23

Deaths in custody
Accidental deaths in constructions, mines, quarries

Question 24

What are the primary functions of an inquest? (3)

Answer 24

Public ascertainment of facts
Focusing public attention on and initiating response to preventable deaths
Satisfying the community that the circumstances surrounding the death will not be overlooked, concealed or ignored

Question 25

Describe the preventative aspect of an inquest. (3)

Answer 25

Recommendations aimed at death avoidance
Majority are acted upon, provided they are reasonable and practical
Often address policies/procedures, training issues

Question 26

What is the oversight council?

Answer 26

Independent advisory agency providing oversight over OFPS and OCC

Question 27

What is the purpose of the oversight council?

Answer 27

Ensure death investigation services are provided in an effective and accountable manner

Question 28

Who had the lowest signs/symptoms of depression, anxiety, PTSD?

Answer 28

forensic pathologists