Ontario’s Death Investigation Oversight Council

Overview

Death investigations in Ontario are led by the Office of the Chief Coroner (OCC) and the Ontario Forensic Pathology Service (OFPS). They work together to investigate deaths and hold inquests to ensure that no death is overlooked, concealed or ignored. The findings are used to support the administration of justice and generate recommendations to help improve public safety and prevent further deaths.

The role of the council

The Death Investigation Oversight Council (DIOC) is an independent, advisory body that oversees the chief coroner and the chief forensic pathologist by advising and making recommendations to them on:

• financial resource management
• OCC and OFPS strategic planning
• quality assurance, performance measures and accountability mechanisms
• appointment and dismissal of senior personnel
• the exercise of the power to refuse to review complaints
• compliance with the Coroners Act and its regulations
• whether or not to call a discretionary inquest
• any other matter that is required

Formation of the council

The council was created in 2010 as a result of the Inquiry into Pediatric Forensic Pathology in Ontario (commonly referred to as the Goudge Inquiry).

The Goudge Inquiry was a judicial inquiry to determine the state of Ontario’s forensic pathology services. This inquiry made several recommendations that focused on strengthening and modernizing Ontario’s death investigation system, including the need for a governing council to provide enhanced accountability and oversight.

Council members

The council is made up of professionals who collectively have the knowledge and expertise to provide quality oversight and accountability, including:

• medical and legal professionals
• senior heath executives
• government representatives
• members of the public

Appointment process

Members are appointed by the Lieutenant Governor in Council through an Order in Council for a time-limited term.

Find a list of the current members.

Reviewing complaints

The DIOC reviews complaints about a coroner or a forensic pathologist involved in a death investigation in Ontario. All complaints about coroners and forensic pathologists must be reviewed by the chief or their designate first before it is reviewed by the DIOC. If you are unsatisfied with the results of the review, notify the DIOC in writing, and your complaint will be taken into consideration.

After reviewing the complaint, the DIOC may provide recommendations to the chief coroner or chief forensic pathologist to improve Ontario’s death investigation system.

Types of complaints

The DIOC is responsible for reviewing complaints about:

• coroners
• pathologists
• other persons referred to under the Coroners Act who have powers or duties for post-mortem examinations

Complaints the DIOC cannot review

The DIOC has no authority to review complaints about a coroner’s decision regarding:

• whether to hold an inquest
• the scheduling of an inquest
• the conduct of an inquest
• any decisions made during an inquest

Complaints the DIOC may refuse to review include complaints that:

• do not relate to a power or duty of a coroner or pathologist
• are trivial or vexatious or not made in good faith
• do not directly affect the complainant

File a complaint

You must file a complaint with the DIOC in writing by either:

• using the complaint form
• emailing: dioc@ontario.ca

Supporting documents for a complaint

The DIOC will accept all documents that a complainant submits for review. Most often the complaint file includes, but is not limited to, the following documents:

• autopsy reports
• correspondence with the OCC and the OFPS, as well as other relevant correspondence
• police reports, if any
• coroner’s investigation reports
• death certificates
• hospital and medical records

If you need help with documents

If you need help getting these documents, please contact the Office of the Chief Coroner:

• Phone: 416-314-4000
• Toll-free: 1-877-991- 9959
• Email: occ.inquiries@ontario.ca
• Address: 25 Morton Shulman Avenue, 2nd Floor, Toronto ON M3M 0B1

Contact the DIOC for support

Before you submit your complaint, if you have any questions or concerns, you can email the DIOC at dioc@ontario.ca.

Submit your complaint

Submit your completed complaint form and supporting documents directly to the DIOC by mail or email.

• Address: 25 Grosvenor St, 15th Floor, Toronto ON M7A 1Y6
• Email: dioc@ontario.ca

If you need accommodation under the Accessibility for Ontarians with Disabilities Act, please contact us. The DIOC will be able to work with you to submit a complaint.

After your complaint is received

Once you have submitted a complaint, the DIOC will:

1. Acknowledge that we’ve received your complaint.
2. Inform you of our mandate and the next steps in the process.
3. Refer your complaint to the appropriate chief for review if they have not already reviewed. For example, if your complaint is about:
   • a coroner, the DIOC will refer your complaint to the chief coroner for review
   • a pathologist, the DIOC will refer your complaint to the chief forensic pathologist for review
4. Review the complaint.

Reviewing your complaint

The time it takes to review a complaint varies from case to case. During the review process, the DIOC will answer any questions you have about the status of your complaint. You are welcome to contact the DIOC at any time for updates.

After the review is complete

After the review is complete, the DIOC will distribute a reporting letter outlining the results of the review and any recommendations to:

• the chief coroner or chief forensic pathologist
• the person who is the subject of the complaint
• all members of the DIOC
• the solicitor general, if the chief is named as the subject of the complaint

Recommendations are typically geared towards improving the overall death investigation system in Ontario. The DIOC's recommendations are non-binding.

In addition to reviewing your complaint, the DIOC may refer it to another appropriate body (such as the College of Physicians and Surgeons of Ontario), depending on the nature of the complaint. In that situation, you will be notified.

Resources

Legislation

Sections 8.1 to 8.4 of the Coroners Act established the Death Investigation Oversight Council.

Office of the Chief Coroner and Ontario Forensic Pathology Service

Find information about the Office of the Chief Coroner or the Ontario Forensic Pathology Service.

Other organizations and agencies

If families have questions or concerns that are not addressed through the complaint process, or that do not fall within the DIOC's responsibilities, the DIOC may direct you to other organizations or agencies, including:

• Bereavement Authority of Ontario
• Centre of Forensic Sciences
• College of Nurses of Ontario
• College of Physicians and Surgeons of Ontario
• Ministry of Health
• Ministry of Long-Term Care
• Law Enforcement Complaints Agency
• Patient Ombudsman