Coroner Guest Lecture Flashcards
How many deaths were there in ON in 2023, and how many were investigated by the office of the coroner?
121,000 deaths
21,000 investigated
What is the vision and mission of the office of the coroner?
High-quality death investigations for a safer and healthier ON
Give examples of some of the objectives of the office of the chief coroner.
Case-centered approach
Commit individually to ensuring quality work as a team to transform the organization
Produce consistent, high quality, useful outputs
What percentage of Ontarians choose cremation?
70-80%
How many people die of drug-related deaths daily in ON?
~7-8 people
What five questions must be answered when someone dies?
Who
When
Where
How
Manner of death
Give examples of scientific methods of identifying a deceased. (4)
DNA
Dental records
Medical imaging
Fingerprints
List the expectations of investigating coroners in the performance of their duties. (7)
Knowledge
Communication
Trust
Teamwork
Accountability
Attention to results
Behaviour
List some values of the Office of the Chief Coroner.
Integrity
Responsiveness
Embrace opportunities, change, innovation
Strive toward best practice and best quality
Diversity
Describe the governance of the OFPS and OCC
Part of Ministry of Solicitor General, accountable to minister
List some QA methods for the OCC, OFPS.
Thorough scene investigation
Comprehensive autopsy
Interdisciplinary collaboration
Family engagement
Training and education
Learning points from other jurisdictions
List some complexities in Coronal death investigations.
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
What death investigation system does ON have>
Coroner
List the team members of a death investigation. (7)
Public health
Police
Coroner
Forensic pathologist
Forensic scientists
Consultants
Other agencies
Outline the OCC structure.
Chief coroner
3 Deputy chief coroners
Regional supervising coroners
What are the 5 steps of an autopsy/death investigation?
Scene
External
Internal
Special tests
Reports
Outline coroners act s. 10
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
What are the powers of the coroner? (6)
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
What is a Category A forensic pathologist?
Investigates all types of cases
What is a Category B forensic pathologist?
Investigates only criminally non-suspicious adults
What is a Category C forensic pathologist?
Investigates only criminally non-suspicious children
How many jurors are there in an inquest?
5
When is an inquest mandatory?
Deaths in custody
Accidental deaths in constructions, mines, quarries
What are the primary functions of an inquest? (3)
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
Describe the preventative aspect of an inquest. (3)
Recommendations aimed at death avoidance
Majority are acted upon, provided they are reasonable and practical
Often address policies/procedures, training issues
What is the oversight council?
Independent advisory agency providing oversight over OFPS and OCC
What is the purpose of the oversight council?
Ensure death investigation services are provided in an effective and accountable manner
Who had the lowest signs/symptoms of depression, anxiety, PTSD?
forensic pathologists
