Overview

Death investigations in Ontario are led by the Office of the Chief Coroner and the Ontario Forensic Pathology Service. They work together to provide death investigations and inquests to ensure that no death will be overlooked, concealed or ignored. The findings are used to support the administration of justice and to generate recommendations to help improve public safety and prevent deaths in similar circumstances.

Death investigation process

Death investigation is a process where a coroner or forensic pathologist seeks to understand how and why a person died. A coroner or forensic pathologist must answer five questions when investigating a 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)

Information may be obtained from several sources including, but not limited to:

  • family
  • co-workers
  • neighbours
  • doctors
  • hospital records
  • police and other emergency service workers

Coroners investigate deaths that appear to be from unnatural causes or natural deaths that occur suddenly or unexpectedly. Additionally, a coroner may become involved when concerns are raised regarding the care provided to an individual prior to death.

Reportable deaths

Certain types of deaths must be reported to a coroner, such as:

  • deaths that occur suddenly and unexpectedly
  • deaths at a construction or mining site
  • deaths while in police custody or while a person is incarcerated in a correctional facility
  • deaths when the use of force by a police officer, special constable, auxiliary member of a police force or First Nations constable is the cause of death
  • deaths that appear to be the result of an accident, suicide or homicide

Read the Coroners Act for a full explanation of reportable deaths.

While deaths are generally reported to the coroner by health care workers or the police, anyone, including a family member, should immediately contact the police and a coroner when a reportable death occurs.

Funeral or ceremonial planning

Funeral or ceremonial planning may be delayed if an autopsy is needed or if the death investigation takes additional time. Coroners and pathologists are aware that religious, spiritual, or cultural practices may dictate time frames for funeral planning and other ceremonies or services. In such cases, families should notify the coroner immediately so that every effort can be made to accommodate these requests.

In most cases, the family makes arrangements to have the body transported from the place of death to the service provider chosen by the family. In some instances, the coroner will have the body transported to a hospital or forensic pathology unit for further examination, such as an autopsy.

Autopsy

An autopsy, also known as a post-mortem examination, is a process where a pathologist or forensic pathologist examines the deceased’s body to help determine cause of death. An autopsy usually includes the examination of internal organs.

The coroner, often in consultation with a forensic pathologist, will decide if an autopsy is needed. The coroner will carefully assess any concerns expressed by the family but will proceed with ordering an autopsy if they believe it is needed to inform the death investigation. The coroner’s decision is legal and binding.

In rare circumstances, an organ (usually the brain or heart) may need to be kept after an autopsy for further testing. The coroner will notify the family and ask for their direction about how the organ should be treated after this work is complete.

For more information on organ retention, email OrganRetention@ontario.ca

Death investigation results and death certificates

Immediate family members or a personal representative can request the death investigation results by either:

  • written request to the regional office
  • completing and submitting a request form

You can get the forms either:

The investigating coroner will provide the report once they complete the death investigation. The length of time needed to complete an investigation varies depending on its complexity, including the number of tests required. Each death investigation is unique. Family members can contact the investigating coroner or the regional office for an update.

For information on ordering a death certificate, please visit ServiceOntario or call Tel: 416-325-8305 or Toll-free: 1-800-461-2156 (Ontario only).

Inquests

An inquest is a public hearing designed to focus public attention on the circumstances of a death through an objective examination of facts. At the conclusion of an inquest, the five-person jury often makes useful recommendations that may prevent further deaths.

There are two types of inquests:

  • mandatory (required by law)
  • discretionary (at the discretion of the coroner)

Learn more about inquests and view the current schedule.

Death investigation oversight council

Death Investigation Oversight Council (DIOC) is an independent advisory agency that oversees coroners and forensic pathologists in Ontario. The council provides advice and makes recommendations to the Chief Coroner and the Chief Forensic Pathologist on matters that include:

  • financial resource management
  • strategic planning
  • quality assurance
  • performance measures and accountability mechanisms
  • compliance with the Coroners Act
  • the administration of a public complaints process

Contact us

Death Investigation Oversight Council
25 Grosvenor Street, 15th Floor
Toronto, Ontario
M7A 1Y9

Office of the Chief Coroner and Forensic Pathology Service
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

Regional supervising coroner offices

Central Region

Boundaries: Durham, Muskoka, York
Central East (formerly Brampton) office
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

Boundaries: Halton, Peel, Simcoe, Wellington
Central West (formerly Guelph) office
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

Toronto

Boundaries: Toronto East (east of Yonge St.)
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

Boundaries: Toronto West (west of Yonge St.)
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

East Region

Boundaries: Northumberland, Haliburton, Kawartha Lakes, Peterborough, Frontenac, Hastings
Lennox & Addington, Prince Edwards County Kingston office
366 King Street East, Ste. 440
Kingston, Ontario
K7K 6Y3

Boundaries: Lanark, Leeds & Grenville, Stormont, Dundas and Glengarry, Prescott-Russell, Renfrew, Ottawa
Ottawa office
75 Albert Street, suite 701
Ottawa, Ontario
K1P 5E7

West Region

Boundaries: Bruce, Chatham-Kent, Elgin, Essex, Grey, Huron, Lambton, Middlesex, Perth, Oxford
London office 235 North Centre Rd., Ste. 303
London, Ontario
N5X 4E7

Boundaries: Brant, Dufferin, Haldimand, Hamilton, Niagara Norfolk, Waterloo
Hamilton office
119 King Street West, 13th Floor
Hamilton, Ontario
L8P 4Y7

North Region

Boundaries: Algoma, Cochrane, Kenora, Rainy River, Thunder Bay
Thunder Bay office
189 Red River Road, 4th Floor
PO Box 4500
Thunder Bay, Ontario
P7B 6G9

Boundaries: Parry Sound, Manitoulin, Nipissing, Sudbury, Timiskaming, Algoma, Cochrane
Sudbury office
199 Larch Street, 2nd Floor
Sudbury, Ontario
P3E 5P9

Updated: November 08, 2021
Published: November 05, 2021