Overview

Regular monitoring and oversight are key components of the federal and provincial Medical Assistance in Dying (MAiD) legislation. Under the Coroners Act, Ontario’s Office of the Chief Coroner (OCC) is responsible for monitoring and oversight of MAiD deaths in Ontario. The Coroners Act mandates that all MAiD deaths must be reported to the OCC. The OCC evaluates compliance with legislative and regulatory requirements and determines if investigation of the death is required.

This updated MAiD review and oversight policy is effective as of January 5, 2026.

Review and oversight process

The MAiD death review and oversight process includes informal and formal feedback mechanisms based on a tiered ranking response approach. As MAiD practice have evolved, we recognize the need for enhanced MAiD oversight.

Following the modernization of the MAiD death reporting structure (implemented January 2023) and stakeholder feedback, we recognize the opportunity for a more transparent and standardized oversight model. This new model has clearly defined escalation pathwaysto respond to legislative and non-legislative concerns identified in MAiD death reviews.

The following revision of the tiered oversight response system provides a more structured and consistent approach to the oversight of MAiD in Ontario.

Role of the Office of the Chief Coroner MAiD Review Team (MRT)

Oversight

All MAiD deaths are subject to review by the Office of the Chief Coroner (OCC) MAiD Review Team (MRT) to:

  • ensure compliance with legislative and regulatory requirements
  • review the approach taken during MAiD assessments and provisions

Practitioners are responsible for providing all information required by the OCC MRT to support the review of each death.

The review process involves:

  • analyzing each case and
  • engaging with practitioners to clarify any missing or inconsistent information
  • confirming that requirements in the Criminal Code of Canada have been met
  • providing feedback where appropriate

Monitoring and reporting

The Office of the Chief Coroner is the designated recipient of federally reportable information for MAiD deaths on behalf of Health Canada. As per the Regulations for the Monitoring of Medical Assistance in Dying, the MRT receives all federally required information from MAiD practitioners’ via completion and submission of the MAiD Death Report (MDR). The data collected is submitted to Health Canada on behalf of MAiD practitioners. When MAiD is provided or self-administered, the MAiD provider or prescriber must submit a MaiD death report and any applicable supporting documents to the review team by the end of the next business day following the MAiD death.

Review

The review team reviews the submitted death report and additional MAiD related documentation for compliance with the applicable legislation, regulation and practice standards. In cases where the documentation is incomplete or clarification is required, team members will contact the MAiD practitioner to request additional information or seek clarification and provide an opportunity for the practitioner to respond. Feedback will be provided to a practitioner or assessor when issues with adherence to legislated requirements or practice deviations are noted, in accordance with the oversight framework.

Investigation

Investigation into the circumstances of a MAiD death will be determined by the MRT, under the direction of the Chief Coroner and in accordance with sections 10 and 10.1 of the Coroners Act. An investigation may be deemed necessary if there are:

  • issues with adherence to legislative eligibility criteria
  • issues with procedural safeguards
  • reported public concerns
  • care-related concerns

Practitioner collaboration with the MRT

Medical and nurse practitioners, as MAiD providers or assessors, are expected to understand their MAiD related:

  • responsibilities under federal legislation
  • regulation
  • professional standards and guidance
  • federal reporting responsibilities

They are also expected to be responsive and comply with any requests for information or clarification from the MRT, and to provide the requested information in a timely manner, as directed under the Coroners Act.

Review and oversight framework updates

A summary of the revisions of the OCC MAiD oversight response approach includes:

  • removal of dedicated level rankings for each legislative criteria
  • addition of standardized notice responses for legislative adherence issues
  • addition of response process for non-legislative or practice issues
  • addition of an audit process involving a stepwise escalation response process for identified patterns of legislative adherence concerns and non-legislative concerns

The eligibility criteria and required safeguards for providing MAiD can be found in section 241.1 of the Criminal Code.

The MRT recognizes that administrative errors and misinterpretations of the applicable legislative requirements may occur and that the response to such errors or misinterpretations could potentially have an impact on practitioner engagement in MAiD care. Oversight responses that support practice reflection and suggested improvement are most common for first-time or infrequent compliance concerns. However, this approach would not apply to serious breaches of the Criminal Code of Canada or situations where the practitioner is believed to have knowingly disregarded their obligations.

The MAiD Review Team approach will include responses for both legislative and non-legislative or practice concerns that will reflect repeated issues by the same practitioner. When oversight action is taken, including providing education, practitioners should reflect on the responses with intent to improve their practice going forward. Identification of similar practice concerns or repeated legislative or non-legislative concerns will follow the escalation process of the oversight response framework.

The response process will follow the same structured escalation approach for legislative and non-legislative issues that includes a maximum number of responses from the OCC before requesting practitioner response. The escalated response approach will include referral to the regulatory college when repeated issues of legislative or non-legislative concerns occur or there is an egregious lack of adherence to the Criminal Code.

Legislative concerns

Legislative concerns refer to issues, interpretations, or implications related to the Criminal Code of Canada and the statutory framework governing MAiD. These concerns may include:

  • compliance with eligibility criteria
  • adherence to procedural safeguards
  • legal responsibilities of healthcare providers and institutions, as outlined in the legislation

Non-legislative concerns

Non-legislative concerns encompass practice-related and regulatory issues associated with the assessment and provision of MAiD, which fall outside the scope of the Criminal Code. These concerns involve operational aspects, such as:

  • documentation practices
  • reporting errors
  • quality of care
  • adherence to ethical standards in the provision of MAiD

Non-legislative concerns may also involve adherence to best practices, and healthcare professionals' conduct in relation to MAiD. The goal of addressing non-legislative concerns is to ensure that the MAiD assessor or provider’s practice aligns with the standards of care and safety for patients.

The MRT is committed to ensuring transparency and open communication regarding the review and oversight process. Awareness of the OCC MRT oversight approach will enable understanding of and the rationale for the expectations and outcomes of the updated review and oversight response process. Please refer to the following appendices for more detailed information:

Appendices

  • Appendix A provides the OCC MAiD Review Team response approach to oversight.
  • Appendix B provides the oversight response for legislative adherence concerns.
  • Appendix C provides the oversight response for non-legislative or practice concerns.
  • Appendix D provides the mandatory legislated eligibility criteria and safeguard requirements.
  • Appendix E provides the MAiD Review Team Review document which establishes the review process by a MAiD review team member. This allows MAiD practitioners to understand the expectations for fulfillment of the legislative requirements for MAiD reporting as well as when contact from the MAiD Review Team may occur.

Inquiry process regarding oversight responses

Medical and nurse practitioners who wish to inquire further or offer feedback related to their experience with the administrative approach followed in the MAiD oversight process may do so by contacting the MAiD Review Team manager by email at: occ.inquiries@ontario.ca.

All concerns will be treated confidentially and equitably. Please ensure the subject of the email includes “MAiD manager — OCC Framework” and provide any pertinent details while respecting confidentiality, where required.

Types of concerns

Concerns related to the administrative review process, professionalism of the MAiD Review Team, and oversight actions relating to this policy are within the scope of the MRT and will typically be resolved mutually. Where concerns are expressed about a decision to refer a MAiD death to a regulatory college or law enforcement, discussion of the circumstances leading to the referral is available to practitioners to identify opportunities for education or improvement of future MAiD care, but the decision is not reversible.

What to expect from the resolution

Once a concern has been submitted to the manager, MAiD Review Team, the complainant can expect a response confirming the receipt of the concern and a timeline for a response. Examples of a resolution may include acknowledgement of an opportunity for quality improvement in the operation of the MAiD review process or providing further information on why the oversight response was provided. If the resolution is not satisfactory to the practitioner, escalation to the Chief Coroner, and further to the Death Investigation Oversight Committee (DIOC) can be requested.

Appendix A: MAiD Review Team oversight response level definitions and criteria

Level 1: Informal conversation

An informal conversation may occur with a MAiD practitioner for first time occurrences of reporting concerns, minor documentation issues, MAiD Death Report (MDR) errors and others. Informal conversations will be documented and may proceed to further action or feedback if there are repeated issues. See appendix C.

An informal conversation will not apply to issues with compliance with legal requirements or regulatory concerns.

Level 2: Educational email

This applies to issues with non-compliance with best practices or policies, guidelines and standards (for example, documentation or record keeping practices, professionalism) from the regulatory colleges. The MAiD Review Team (MRT) will provide feedback and education to the MAiD practitioner or assessor in response to variations in best practice. The variation identified, independently, does not have significant impact on the integrity of MAiD assessment or MAiD provision. The intention of the educational feedback is to support practice improvement and alignment with guidelines and standards. See appendix C.

Level 3: Formal notice email

This applies to contraventions of the MAiD legislation including eligibility criteria and safeguards. The MRT will provide a formal notice to the MAiD practitioner in response to identified concerns with eligibility criteria or non-adherence to procedural safeguards. Repeated issuing of level 3 notices will result in stepwise escalation in the oversight approach, ultimately leading to a request for the practitioner to acknowledge the previously provided feedback and notices and steps taken to address the issues identified, and a potential report to the appropriate regulatory college. See appendix B.

Level 4: Report to applicable regulatory body

This applies to legislative, regulatory, and other concerns that are felt to be appropriate for referral to the regulatory college. Dependent on the circumstances, a referral to the applicable regulatory college may be for a first occurrence (see appendix D, Level 4 response) or repeated issues of concern. Referral to the regulatory college will enable the college to complete an independent assessment and follow up with any action considered necessary under the college mandate. Referral to the college requires team discussion and review with the Chief Coroner. See appendix B.

Level 5: Report to police and report to applicable regulatory body

This applies to legislative and other concerns that are felt to be appropriate for report to the police. Report to police requires team discussion and review with the Chief Coroner. See appendix B.

If certain legislative eligibility criteria or procedural safeguards are not followed a direct level 4 or level 5 response may be instituted regardless of any prior responses to the practitioner. The specific criteria and safeguards that would result in a direct referral to a regulatory college or police are listed in appendix D, level 5 response.

Appendix B: Response and escalation process for legislative adherence concerns

Legislative concerns and response process

Step 1: First legislative concern - level 3 formal notice e-mail to MAiD provider or assessor

Step 2: Second legislative concern - level 3 formal notice e-mail to MAiD provider or assessor

Step 3: Third legislative concern - level 3 formal notice e-mail and initiation of the audit process. An audit process for the subsequent three MAiD deaths reported will be initiated to monitor legislative adherence. If no additional concerns are identified during the audit process, the audit will be deemed complete, and the response process will be reset. If further issue(s) is/are identified, an audit escalation process progresses through the next steps (including steps 4 and 5, if applicable).

Step 4: Fourth legislative concern - level 3 formal notice e-mail with a request for response from the practitioner. A continued audit process to monitor legislative adherence will continue and the manager of the MRT will be notified.

Step 5: Fifth legislative concern - level 4 report to the applicable regulatory body due to a continued pattern of non-adherence following review and discussion with the MAiD team manager and the Chief Coroner. The practitioner will be notified that a report was made.

Appendix C: Response and escalation process for non-legislative concerns

Non-legislative concerns response process

Step 1 – Level 1: Informal conversation

  • For minor, first-time documentation issues/errors
  • Reporting concerns (for example, incorrect MDR submission)
  • Issue documented, no formal action unless repeated

Step 2 – Level 2: Education email

  • For breaches of best practice or regulatory guidance (for example, incomplete documentation, record keeping)
  • Triggers educational guidance and expectations for correction

Step 3 – Level 3: Notice letter and audit of next three successive submissions

  • Issued after two prior practice issues
  • Practitioner will be notified that they will be on an audit process with request of records for their next three MAiD death notifications

Step 4 – Level 3: Notice letter and request for practitioner response

  • Practitioner will be requested to submit a response for addressing concerns
  • The practitioner response is not mandatory, rather an opportunity to acknowledge feedback
  • Ongoing audit process

Step 5 – Report to regulatory college

  • Triggered by continued non-compliance
  • Referral to applicable regulatory college

Appendix D: Legislative criteria and safeguards for MAiD assessors and providers

Level 3 response will be issued where adherence to the following legislative criteria have not been addressed

MAiD assessors must ensure the following legislative criteria are satisfied for all MAiD requests:

  • you have confirmed that you are independent of the individual requesting MAiD (the “requester”)
  • you have confirmed that you are independent from the other assessor
  • the requester is eligible for health services funded by government in Canada.
  • the requester provided informed consent after having been informed of means available to relieve their suffering, including palliative care
  • you prepared a written opinion confirming that the requester met eligibility criteria and if you were not the provider or prescriber, you shared the written opinion with the provider or prescriber.

MAiD assessors must ensure the following legislative safeguards are addressed for all MAiD requests:

As a MAiD provider or prescriber, you must have:

  • formed the opinion that all the eligibility criteria have been met
  • ensured that the written request was signed and dated by the requester or their proxy
  • confirmed that when signed by a proxy, that person was independent by:
  1. confirming the proxy signer is not a beneficiary under the will of the requester
  2. confirming the proxy signer is not a recipient of a financial or other material benefit resulting from the death
  • ensured that the written request was made after the requester was informed by a practitioner that they have a grievous and irremediable condition
  • confirmed that the written request was signed and dated by the requester in the presence of an independent witness
  • confirmed that the independent witness signed and dated the written request in the presence of, and on the same date as, the requester
  • confirmed that the witness is independent by:
  1. confirming the witness is not a beneficiary under the will of the requester
  2. confirming the witness is not a recipient of a financial or other material benefit resulting from the death
  3. confirming the witness does not own or operate a health care facility where the requester resides or gets treatment
  4. confirming that the independent witness was not directly providing unpaid health care services or personal care to the person requesting MAiD (for example, family, friend or extended family)
  5. confirming that an independent witness who is paid to provide health care services or personal care is not the MAiD provider or prescriber or a MAiD assessor
  • ensured that the requester is aware they can withdraw their request at any time and in any manner
  • confirmed the second opinion was independent by:
  1. ensuring there is no connection between the provider or prescriber and the assessor that could compromise independence (such as a mentor-mentee relationship)
  2. ensuring the assessor is independent of the requester (for example, not a beneficiary or any other relationship that would affect their objectivity)
  3. ensuring the provider/prescriber does not know or believe they are connected to the requester or the assessor in any way that would affect their objectivity
  • ensured that the requester was given an opportunity to withdraw their request and gave their express consent to receive MAiD immediately before the procedure.
  • took all necessary measures to provide a reliable means by which the requester could have understood the information that was provided to them and communicated their decision, if the requester had difficulty communicating
  • informed the pharmacist that the medication being sought is for the purposes of providing MAiD

MAiD providers must ensure the following legislative safeguards are addressed for final consent prior to provision:

As MAiD provider/prescriber, you have ensured that the requester:

  • was given an opportunity to withdraw their request
  • gave their express consent to receive MAiD immediately before the procedure except where a waiver of final consent was invoked due to a loss of capacity (Track 1 only)

MAiD assessors must ensure the following legislative safeguards are addressed for Non-Reasonably Foreseeable Natural Deaths (NRFND) Track 2 only:

MAiD providers or prescribers must have:

  • ensured that consultation occurred with a practitioner who has expertise in the condition that was causing the person’s suffering, if neither you nor the other independent assessor has expertise
    • share the results with the other practitioner
  • discussed with the other independent assessor and the requester the reasonable and available means to relieve their suffering
  • come to agreement with the other assessor that the requester had given serious consideration to other available means to relieve their suffering
  • ensured that there were at least 90 clear days between the day on which the first assessment for eligibility began and the day on which medical assistance in dying occurred
  • ensured that if the assessment period was shortened, this was due to risk of an imminent loss of capacity to consent and both assessors were in agreement

MAiD assessors must ensure the following legislative safeguards are addressed for advanced consent in self-administration:

MAiD providers or prescribers must have:

  • a written arrangement with the requestor to administer a substance to cause the death of that person in accordance with the terms of the written agreement, if the requestor self-administered a substance and did not die within a specified period and lost the capacity to consent.

Level 4 response (Report to regulatory college) will be issued where adherence to the following legislative criteria have not been addressed

As the MAiD provider/prescriber or assessor, you have ensured all of the following criteria have been met:

  • the person had a grievous and irremediable medical condition:
  1. they have a serious and incurable illness, disease, or disability
  2. they are in an advanced state of irreversible decline in capability
  3. the requestor’s illness, disease, or disability or that the state of decline causes them enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable.
  • ensured that there was a second independent written opinion from an assessor confirming the eligibility criteria were met.
  • before invoking a waiver of final consent, you ensured that:
  1. before the person lost capacity, they met all the eligibility criteria for MAiD
  2. the person entered into a written agreement that the provider would administer a substance to cause their death on a specified date
  3. in the written agreement, the requester consented to the administration of a substance to cause their death on or before the day specified in the arrangement if they lose capacity to consent to receive MAiD prior to the day
  4. the person lost capacity to consent to receiving MAiD
  5. the requester did not demonstrate, by words, sounds, or gestures, refusal to have the substance administered or resistance to its administration

Level 5 response (report to law enforcement) will be issued where legislative compliance was not clearly established

MAiD providers, prescribers or assessors must ensure that:

  • the person was at least 18 years of age
  • the person was able to make decisions with respect to their health
  • the request was voluntary and not made because of external pressure

Appendix E: MAiD Review Team review procedure

This appendix outlines the review process by a MAiD Nurse Coroner Investigator. This is a resource for MAiD practitioners when completing legally required MAiD reporting. It also includes examples of when contact with the practitioner by the MAiD Review Team (MRT) is likely to occur if information is not available in the submitted records.

Completion of the MAiD Death Report (MDR) form and MRT review

  • Submit by end of next business day following the requirements for all MAiD deaths
  • Complete Section 1 Triage identifying case characteristics for possible review or investigation
  • Ensure accurate information is provided regarding the requester (for example: date of birth, health card number, correct spelling of name and next of kin contact information)
  • Complete all mandatory sections indicated with a *
  • For Section 5 Confirmation of Eligibility, any items marked as “no” or “did not assess” will be followed up by the MRT as this indicates the person was NOT eligible for MAiD
  • For Section 6 Mandatory Reporting, areas of potential uncertainty in the completion of palliative care or disability support services responses will be clarified if the entry appears inconsistent with other information provided
  • For Section 11 Cause of Death, if a potential injury or fracture will be included in the cause of death provided on the Medical Certificate of Death, the MAiD provider is required to contact the MAiD Coroner Investigator immediately following the death and prior to completing the Medical Certificate of Death (per Section 10 of the Coroners Act).
  • If the MAiD provider entered an injury/non-natural condition in the cause of death section, they will be contacted by the MAiD Coroner Investigator to discuss the circumstances
  • Additional information or data that may prompt follow up from the MRT includes:
    • no next of kin provided — it is important to include this at all times to ensure aftercare arrangements are in place – provide details in Section 12 of the MDR
    • no home address provided
    • usual place of residence indicated as a correctional facility, shelter/group home or “other”
    • family members who acted as witnesses or third-party signers
    • involvement of third assessor or provider
    • potential communication issues identified
    • waiver of final consent invoked
    • complications with the procedure

Submission of records

  • All records must accompany the MDR for deaths involving:
    • a dual provision
    • frailty/unclear cause of death
    • track 2 safeguards
    • dementia
    • potential capacity concerns
    • care or provision related concerns
    • family concerns
    • MAiD self-administration

Instructions for records submission are found in section 1 of the MDR. Records must be submitted for all cases other than when “None of the above” is completed in the triage section. For clarification of what documents are required, please refer to the Checklist for MAiD Providers.

Areas of focus for specific death circumstances

  1. Dual provision (two individuals requesting MAiD simultaneously):
    1. review will include evaluation for:
      • evidence of voluntariness in documentation
        • involvement of four separate assessors (considering regional availability)
      1. if separate assessors not available for each requester, then documentation for how independence was maintained
      2. independence of each requester’s assessment
  2. Frailty/unclear cause of death:
    1. evidence of recent falls with or without injury
      1. catastrophic event or significant change in medical condition
  3. Non-Reasonably Foreseeable Natural Death (NRFND)/track 2 deaths:
    1. evidence of confirmed eligibility followed by safeguard determination clearly documented
      1. documentation of the date and rationale for beginning of assessment period
      2. documentation of track 2 safeguards as met or completed:
  • documentation of consultation with professional with expertise if required or statement/documentation of expertise of assessor(s)
  • documentation of communications between the two assessors including the options to alleviate suffering, and communication with requester
  • documentation that the requester was made aware of options and the available means to alleviate suffering by both assessors
  • documentation of discussions about the requester’s considerations of the options for treatment
    1. If the 90-day assessment period was shortened due to a loss of capacity, clear documentation of the change in condition of the requester and that it has been discussed or documented by both assessors
  1. Dementia and/or potential capacity concerns:
    1. documentation supporting capacity assessment for:
      • understanding of disease and options for treatment
        • appreciation of individual situation
        • evidence of reasoning of options/risks/benefits
        • communication of a clear choice
      • clearly documented evidence of irreversible functional decline regarding stage of dementia
      1. documentation detailing when a waiver of final consent is invoked, including determination of loss of capacity clearly established with no resistance
  2. Care or provision related concerns or family concerns shared with practitioner:
  3. nature of concern and attempts to address — additional details can be provided in Section 12 of the MDR
  4. If noted during family call with MRT, additional clarification may be sought from the provider or assessor
    1. For deaths involving injury, accident, or provision in a correctional institution:
  5. calls to MAiD Review Team are required at the time of death for discussion of case before completion of Medical Certificate of Death.
  6. Details on aftercare arrangements and the name of the funeral home will be requested in addition to next of kin contact.
  7. All records to be submitted with submission of MDR
  8. Secondary assessors:
    1. if records are requested, secondary assessor documentation of eligibility are required and reviewed for demonstration of how the eligibility criteria were met by the requester
    2. clinician aid C does not fulfill the documentation requirement for MAiD assessments
    3. for track 2, clear documentation by the secondary assessor of communication with primary assessor and requester regarding alternative options available to relieve suffering and expertise if provided
  9. Comorbid mental illness:
    1. clear documentation of the underlying grievous and irremediable condition for which the person is seeking MAiD, and that mental illness is not the sole condition or primary reason for requesting MAiD
    2. documentation of psychiatric evaluation if obtained
    3. decision making during a period of stability and assessments determining that request for MAiD is rational
    4. assessment of capacity for decision making regarding MAiD
    5. if history of suicidality is present, documentation clarifying any treatment and care provided or suicide prevention supports that were engaged
  10. MAiD self-administration:
    1. clearly documented date of when the medications were prescribed
    2. date the medications was self-administered and where
    3. any complications with the self-administration (did death occur) and presence of the practitioner during self-administration
    4. if a written arrangement was completed prior to a loss of capacity to consent to MAiD was the medication administered according to the arrangement by the practitioner
    5. clinician aid D-2 advance consent for self-administration completed

Follow up calls to next of kin

  • Any issues or feedback during the follow up call with next of kin will be considered for possible investigation of the MAiD death as required
  • Records will be requested to evaluate if concern(s) are raised by the next of kin

Documentation standards

Additional resources

Guidance resources to support MAiD care are available through the Canadian Association of MAiD Assessors and Providers (CAMAP). A full list of available documents can be found on: CAMAP Publications and Guidelines - CAMAP | ACEPA

The following documents have been developed by the Office of the Chief Coroner and are available for practitioners to inform MAiD practice. They can be obtained by contacting occ.maid@ontario.ca or occ.inquiries@ontario.ca.

  • For support in the management of Track 2/NRFND: Medical Assistance in Dying Track 2 Lessons Learned (May 2024)
  • Considerations for assessing voluntariness in dual provisions: Review of Voluntariness in Joint Medical Assistance in Dying Provisions (May 2023)