Coroner’s inquests

An inquest is a public hearing conducted by a coroner, lawyer, or retired judge before a jury of five community members. Inquests are held to inform the public about the circumstances of a death. The jury makes conclusions about the facts of the death and may make recommendations to prevent further deaths based on the evidence heard at the inquest. 

Mandatory inquest

Mandatory inquests are held in certain circumstances, including when:

• a death occurs on the job at a mine, pit, or quarry
• a person dies from non-natural causes while committed to a correctional institution
• a person dies while detained by, or in the custody of a peace officer
• a death occurs when the use of force by a police officer, special constable, auxiliary member of a police service or First Nation officer, was a cause of the person’s death
• a death of a child is the result of a criminal act of a person who has custody of the child, if certain circumstances are met
• a death occurs while being physically restrained and detained in a psychiatric facility, hospital or secure treatment program

Discretionary inquest

An inquest may be held at the discretion of the coroner if they determine that:

• an inquest would assist with a more accurate determination of five facts about the death, specifically:
  • who the deceased was
  • how and when the deceased came to their death
  • the cause and manner of death
• it is desirable for the public to have an open and full hearing of the circumstance of a death through an inquest
• a jury could make useful recommendations to prevent further deaths

Requested inquest

A relative or personal representative of the deceased person may request an inquest by submitting a request in writing to the investigating coroner. The request will be presented to the regional supervising coroner to help determine whether an inquest should be conducted.

There is no time limit between the date of death and the convening of an inquest.

Annual review of construction deaths

A mandatory review of all accidental deaths at a construction project, except for inquests held at the discretion of the coroner, is conducted each year. Construction deaths previously required a mandatory inquest.

The construction death review is led by one or more coroners appointed by the chief coroner and supported by an advisory committee including construction sector experts. The review examines the circumstances of an individual’s death and explores broader, systemic issues to make recommendations that may help to prevent further deaths.

The review, including findings, conclusions, and recommendations to prevent further deaths, will be posted annually online on June 30.

An inquest can be held if the family or personal representative of a worker who dies in an accident at a construction site requests it before, or within one year after, the day of the release of the annual report.

Inquest jury

Service on an inquest jury is an important civic duty in Ontario. Inquest juries:

• listen to the evidence presented at an inquest
• answer five specific questions related to the death at the conclusion of an inquest (known as the inquest verdict)
• may issue recommendations, where appropriate.

Learn more about jury duty in Ontario.

Jury selection

The inquest jury consists of five people selected by the coroner’s constable from a list of jurors from the community. Potential jurors are selected from the jury roll received from the Provincial Jury Centre in the same way as they are selected for civil or criminal trials in Ontario.

If you have been selected as a potential juror for an upcoming inquest, you will receive an email (a summons) from the Office of the Registrar of Inquests. The summons will require you to attend a virtual meeting with a coroner’s constable to participate in the jury selection process. Being summoned to jury duty does not mean you will be selected to be part of a jury.

If you are selected to be a juror, the coroner’s constable will provide information about what to do next.

If you have questions about the inquest jury selection process, please contact the Inquest Registrar at: 647-329-1890 or occ.inquests.registraroffice@ontario.ca.

The role of the inquest jury

The jury must deliver a verdict answering the five questions regarding the death:

• who (identity of the deceased)
• when (date of death)
• where (location of death)
• how (medical cause of death)
• by what means (natural causes, accident, homicide, suicide or undetermined)

The verdict does not need to be unanimous and can be reached by majority. Juries may make recommendations based on the evidence presented to them, but this is not a requirement.

Inquest juries are prohibited from:

• making any finding of legal responsibility
• expressing any conclusion of law

In their recommendations to prevent further deaths, the jury’s role is not to:

• assign blame
• free someone from blame
• state or imply any judgment

Inquest verdicts and recommendations

The Office of the Chief Coroner posts verdicts and recommendations for all inquests on a rolling five-year basis.

At the conclusion of an inquest, the chief coroner will send the jury’s recommendations to the named organizations. Recipients of the recommendations are asked to respond to the chief coroner outlining how they have considered the recommendations and what steps, if any, they have taken to implement them.

The Office of the Chief Coroner does not have the authority to:

• enforce the implementation of recommendations
• endorse recommendations
• encourage or coerce recipients to implement recommendations

Data on individuals whose deaths were the subject of a coroner’s inquest in Ontario and all inquest recommendations and responses to recommendations are available as a downloadable dataset.

A presiding officer is a coroner, lawyer, or retired judge who presides over the inquest. Individuals with a substantial and direct interest in the inquest, including individuals who may be directly and uniquely affected by potential recommendations, may take an active part in the proceedings. This participation is called standing. A person or party must apply to the presiding officer for standing, and the presiding officer will grant standing if certain legal criteria are met.

Parties with standing

Parties with standing may represent themselves (with some restrictions), or have lawyers or agents represent them. Parties may cross-examine witnesses relevant to their expressed interest and may be permitted to call certain witnesses of their own. However, the presiding officer must find that the evidence of such a witness is relevant and admissible to the proceedings.

Although an inquest may have lawyers representing various (and sometimes opposing) interests, it is essential to remember that no one is on trial and that the jury is not allowed to assign blame in its verdict. An inquest is most effective when the parties work collaboratively.

Family of the deceased

The family of the deceased may wish to seek standing (with or without a lawyer) or observe the proceedings along with the public. Depending on the circumstances, family members may also be called as witnesses at an inquest.

In all inquests, the inquest counsel, investigator and presiding officer are available to hear the concerns of the family and answer their questions at any time during the inquest process.

Transcripts of the proceedings

Transcripts of proceedings are not automatically generated. Requests for transcripts of the proceedings can be provided at a cost by emailing occ.inquests@ontario.ca. The fees for the transcripts are the responsibility of the requestor.

Financial support programs

If you have been granted standing in an inquest, there are two programs, identified below, that may help to offset the costs of your participation. Eligible applicants can apply online and may receive funding from one program only.

Questions regarding the programs or the status of an application can be directed to SOLGEN.Correspondence@ontario.ca.

Coroner’s inquest legal fee reimbursement program

Applicants are eligible to apply for reimbursement of certain costs of legal representation for an inquest under this program if they meet all of the following criteria:

• the applicant is a parent or spouse of the deceased
• the deceased was a victim of crime
• the applicant has been granted standing by the presiding officer at the inquest into the death of their child or spouse

For the purposes of the program, the deceased is considered a victim of crime if there are reasonable grounds to believe that the death was the direct result of conduct by another person that is prohibited under the Criminal Code.

Applicants who are under investigation, charged with, found guilty or convicted of committing the crime that led to the victim’s death are not eligible.

Coroner’s inquest family reimbursement program

Applicants are eligible to apply for reimbursement of the costs of legal representation for an inquest under this program if they meet all of the following criteria:

• the applicant is a parent, spouse, child, sibling or personal representative of the deceased
• the deceased person was involved in a police-related incident, which includes one or more of the following circumstances:
  • a police officer used force against the deceased person
  • the deceased person was detained by or in the custody of a police officer
  • the deceased person was involved in a motor vehicle accident involving a police officer or when in pursuit by a police officer
  • any other circumstance in which the ministry reasonably believes that a police officer’s conduct may have been a contributing factor in the incident
• there are reasonable grounds to believe that the police-related incident may have resulted in, or contributed to, the individual’s death
• the applicant has been granted standing by the presiding coroner at the inquest into the death

The application form and additional information about both programs, including maximum reimbursement amounts are available online.