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 investigations publications and reports.

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 the past, organs were sometimes kept for testing after an autopsy to help investigate and determine the cause of death. Before June 14, 2010, families were not always told that an organ had been kept.

Under Regulation 180 of the Coroners Act, these organs were to undergo disposition on June 14, 2013. The organs will now be kept for at least five more years because it has become clear that people need more time to learn about this difficult issue.

Immediate family members and personal representatives (e.g. those responsible for administering an estate) are invited to contact the Ontario Forensic Pathology Service and the Office of the Chief Coroner if they wish to learn whether an organ was retained in their loved one’s case at OrganRetention@ontario.ca.

Some organs may no longer be available due to past practices. In cases where an organ was retained and is still being stored, the organ can be sent to a funeral home for cremation or burial at the expense of the Ontario Forensic Pathology Service and the Office of the Chief Coroner.

Regulation 180 under the Coroners Act ensures that, when possible, families are notified and their wishes are sought if an organ must be retained after an autopsy.

Please note:
Callers may be asked to provide personal information. This information may be collected pursuant to s. 38(2) of the Freedom of Information and Protection of Privacy Act for the purpose of processing requests regarding retained organs. Questions about the collection of this information can be directed to the issues manager, OCC.Inquiries@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.

Contact us

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, York
Central East office
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

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

Toronto

Boundaries: Toronto East (east to Jarvis Street and south to Lake Ontario)
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

Boundaries: Toronto West (Yonge Street from Steeles Avenue south to Bloor Street)
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

East Region

Boundaries: Leeds and Grenville, Northumberland, Haliburton, Kawartha Lakes, Peterborough, Frontenac, Hastings
Lennox and Addington, Prince Edward County
Kingston office
366 King Street East, suite 440
Kingston, Ontario
K7K 6Y3

Boundaries: Lanark, Stormont, Dundas and Glengarry, Prescott and Russell, Renfrew, Ottawa
Ottawa office
347 Preston Street, suite 350
Ottawa, Ontario
K1S 3H8

West Region

Boundaries: Chatham-Kent, Elgin, Essex, Lambton, Middlesex
London office 235 North Centre Rd., suite 303
London, Ontario
N5X 4E7

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

Boundaries: Wellington, Dufferin, Waterloo, Perth, Bruce, Huron, Grey and Oxford
Waterloo office
Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1

North Region

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

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 including compliance with the Coroners Act.
  • DIOC also administers a public complaints process.

Contact DIOC

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