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What is a coroner?

A body awaiting examination by a coroner. - iStockphoto, Getty Images

You’ll often hear media coverage of a coroner’s inquest and they’re a staple of TV crime shows. Here’s a primer on what coroners do and how their investigations work.

What is a coroner?

A coroner is someone with training in death investigation, who is appointed to probe circumstances surrounding a death and make recommendations to prevent such events from recurring.

They are often medical doctors, but some provincial and territorial laws don’t require this.

Although they investigate deaths, a coroner is independent from the police and they don’t assign civil or criminal responsibility for events causing a death. A coroner is a fact-finder, not a finger-pointer.

What does a coroner do?

A coroner investigates any sudden, unnatural or unexpected death. A death by natural causes probably doesn’t require a coroner’s investigation, but deaths caused by violence, negligence or malpractice would.

When a death fits that profile, the coroner conducts an investigation into the victim and the fatal events. Their report includes:

  • name(s) of the deceased;
  • date and place of death;
  • likely cause of death and description of those circumstances;
  • recommendations to prevent future deaths.

What is an inquest?

After an investigation, the coroner can recommend an inquest, which is a public hearing into the events of a death.

This is done when the coroner feels the public would benefit from information aired at an open hearing.

An inquest can be similar to a courtroom trial. It’s usually presided over by a judge and witnesses testify under oath. Evidence is presented to a small jury, typically composed of five or six members, depending on provincial laws. Mistrials have even occurred in inquests, although very rarely.

Inquests are usually mandatory in construction accidents and for deaths in correctional institutions, unless they’re from natural causes.

What does a jury do?

A coroner’s jury is distinct from a trial jury, as it’s not trying to determine guilt. Instead, this jury produces a verdict similar to a coroner’s report. It includes identities of victims, circumstances and likely cause of death, as well as recommendations to prevent similar deaths.

Those recommendations are then presented to any affected parties, although they are not legally binding.

In one high-profile example, a 2012 inquest into the suicide of a teen at an Ontario jail produced 104 recommendations to Corrections Canada. One of the key recommendations was to ban indefinite solitary confinement for mentally ill inmates, but the agency rejected the idea.

Read more:

Coroners Service British Columbia

The role of the chief medical examiner's office Manitoba