Enquiries and Inquests

When is an enquiry or inquest ordered?
Enquiries are ordered for all unexplained or unnatural deaths.

A public inquest is held only when legislation requires, or when the Chief Coroner considers it in the public interest. An inquest is ordered into the death of any person in custody in a correctional centre or jail.

What is an enquiry?
The purpose of the coroner's enquiry is not to determine criminal or civil responsibility for the death. The coroner may make recommendations to prevent a similar death in the future. The Chief Coroner will provide coroner's recommendations to the appropriate individuals, agencies or departments of government.

The coroner may work with the police, pathologists, investigators from Occupational Health and Safety and the Transportation Safety Board, dental experts, anthropologists and neuropathologists.

The findings of a coroner are reported to the Chief Coroner in the "Report of Coroner." This report summarizes the findings of the enquiry, including the medical cause of death and the manner of death (natural, accidental, suicide or homicide). If the coroner orders a medical examination (autopsy) of the deceased, a report is completed by a pathologist and filed by the coroner.

How long does it take to complete a coroner's enquiry?
Each enquiry varies. It usually takes four months for documentation, the autopsy report and the Report of Coroner to be available.

What happens at an inquest?
Inquests are open to the public and are similar to a judicial process. Witnesses are summoned by the coroner to give evidence, under oath, on their knowledge of the death. The evidence is given before a six-person jury summoned at random from the community where the inquest is held.

Witnesses include any persons able to give material evidence on the cause of death or any other matter being examined at the inquest. After hearing the evidence, the jury gives its verdict by stating the name of the deceased, the time, place and cause of death and any recommendations to help avoid similar deaths. The Chief Coroner will provide these recommendations to the appropriate individuals, agencies or government departments. This process is not to determine civil or criminal responsibility in the death.