An inquest is a public hearing conducted by a coroner before a jury of five community members. Inquests are held to inform the public about the circumstances of a death. Although the jury’s conclusions are not binding, it is hoped that any recommendations suggested, if implemented, will prevent further deaths.

When an inquest is held

Mandatory inquest

Mandatory inquests are held in certain circumstances, including when:

  • a death occurs on the job at a construction site, mine, pit or quarry
  • a death occurs while a person is in custody or being detained (unless, in some circumstances, a death investigation determines the death occurred from natural causes in which case the inquest is discretionary)
  • a death occurs due to an injury sustained or other event that occurred in custody, or when the use of force of a police officer, special constable, auxiliary member of a police force or First Nations Constable is the cause of 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:

  • enough information is known from a death investigation to support an inquest
  • it is desirable for the public to have an open and full hearing of the circumstance of a death
  • a jury could make useful recommendations to prevent further deaths

Inquest upon request

A relative of a deceased may request an inquest by submitting a request in writing to the investigating coroner. The request will be presented to the Regional Supervising Coroners Management Team to determine whether an inquest should be conducted.

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

The inquest jury

The inquest jury consists of five people selected by the coroner’s constable from a list of jurors from the community.

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 future deaths, the jury’s role is not to:

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

Participation in an inquest

A coroner, judge, retired judge or lawyer presides over the inquest. Individuals with a substantial and direct interest in the inquest, including persons who may be directly and uniquely affected by the recommendations, may take an active part in the proceedings. This participation is called standing. A person or party must apply to the coroner for standing.

Parties with standing

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

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.

Transcripts of the proceedings

A court reporter is present during an inquest to record the proceedings. Transcripts of the proceedings can be obtained through the court reporter for a fee.

Financial support programs

If you have been granted standing in an inquest, there are two programs that may help to offset the costs of your participation. Eligible applicants may receive funding from one program only. Please visit the Ontario Central Forms Repository to access the application form and guide.

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 coroner 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 of Canada.

Applicants who are under investigation, charged with 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 their death

The application form and additional information about both programs, including maximum reimbursement amounts, can be found by visiting the Ontario Central Forms Repository.