|For Immediate Release
Wednesday, November 23,
British Columbia Coroners Service
Public Safety and Solicitor
In recent days,
much media discussion has centered on the process by which deaths
are investigated in British Columbia. The Office of the Chief
Coroner's office wishes to clarify the role of the Coroner, and the
role of the Child Death Review Unit.
The Role of the Coroner
Coroners in B.C.
are medical-legal death investigators operating under the authority
of the Coroners Act and the direction of the Regional Coroner who is
subject to the direction of the Chief Coroner.
given their legal powers through appointment by Order-in-Council.
Prior to receiving their appointments, coroners undergo a rigorous
training and mentoring process under the auspices of the Regional
Coroner. Coroners in B.C. are not required to have any prior medical
training, although many do. Coroners do not perform autopsies.
Pathology services are contracted through the Health Authorities.
Most deaths do
not come under the jurisdiction of the coroner. The coroner, in most
circumstances, does NOT have jurisdiction to investigate deaths that
are expected, that are due to natural disease processes, and that
involve a person who is under the regular care of a physician. Those
are, in fact, a significant majority of all deaths in B.C.
Some of those
deaths may be reported to the B.C. Coroners Service because of their
suddenness or unexpectedness. In these cases, the coroner conducts a
preliminary investigation to ensure the information provided is
accurate, and that no other issues are raised which would require a
formal Inquiry to be initiated. Provided the information is correct
and no issues are identified, the Physician's Medical Certification
of Death (the document which gives the cause of death) is signed by
the person's physician, and the B.C. Coroners Service has no further
Section 9 of the
Coroners Act requires coroners to undertake a formal inquiry into
all other deaths that occur in B.C. These include all deaths that
occur through accidents, through suicide, through violence, or from
natural disease process in cases where the person was not under a
such cases, the coroner conducts a full inquiry into the death and
is responsible for signing a Coroner's Medical Certification of
Death. This involves determining not only the medical cause of death
but also the circumstances that led up to the death and any factors
which contributed to the death.
role is solely to determine the facts of a death not to make any
finding of fault or legal responsibility. The Coroner's conclusions
must be objective and devoid of speculation or editorializing.
In each inquiry,
the Coroner considers whether reasonable and practical
recommendations might be made which could help in preventing similar
deaths in the future.
Each inquiry is
concluded with a report called a Judgment of Inquiry which is a
legal and public document. It spells out the identity of the
deceased, the cause and classification of death, provides a brief
description of the circumstances of the death, and lists any factors
found to have contributed to the death. It may also include
recommendations which the Chief Coroner then forwards to the
appropriate "persons, agencies and ministries of government".
An inquest is a
formal court proceeding held to publicly review the circumstances of
a death. An inquest is mandatory if a death occurs in police prison
or lockup or while an individual is in the custody of a police
officer. In all other cases, the decision to call an inquest is
discretionary and is based on the particular circumstances of the
concluded by a Report of a Non Coroner Case are generally completed
within days of the report of a death. Inquiries may take weeks,
months and in some cases, years, depending on their complexities.
Inquests are generally held within a year of the death however,
timelines may vary depending on other proceedings, i.e. criminal
The Role of the Child Death Review Unit
purpose of reviewing a child's death is prevention. One-hundred
percent of the child deaths in the province are independently
reviewed by the Child Death Review Unit (CDRU). The CDRU reviews are
confidential, as both public and personal information about the
deceased and the family may be included.
consists of identifying risk factors involved in a child's death
which may lead to recommendations that could reduce those same risk
factors in other children, thereby preventing deaths. This process
may involve examining medical, social, economic, behavioural,
environmental, systemic and product safety issues. It may also
involve applying injury prevention and control practices assessment
tools to the circumstances of a death.
The process will
follow a public health approach including surveillance, collection
and analysis of data, design and implementation of interventions,
evaluation of outcomes and distribution of findings. The review of a
child's death is not a re-investigation of the investigations
conducted by the various agency participants in the circumstances of
that child's death.
The Coroner has
the ability to make a recommendation to the Chief Coroner through
the Judgment of Inquiry (JOI) at the conclusion of an investigation.
Recommendations forwarded by the Coroner will address prevention
issues that are directly causal to the death and are supported by
the facts presented in the JOI.
focus and real benefit from recommendations is at the level of
aggregate review the ability exists to generate individual
recommendations from the CDRU at any stage of the review process.
Recommendations from the CDRU do not form part of an individual
public report, such as those made within the JOI. The goal of the
CDR recommendation process is evidence based recommendations,
analysis of best practices, and review using a public health model.
The CDRU will
generate a report early in the new year that will cover all its
activities from 2003 -2005. The report will contain statistics on
child deaths and analysis, an accounting of child deaths reviewed,
the nature of recommendations made and possible representative cases
from each classification. The CDRU will generate special reports on
a periodic basis covering various topics of interest or as part of a
research project or in depth analysis of subjects such as "children
in care" deaths, youth suicide, recreational fatalities, sudden
unexpected infant deaths, youth drug abuse, etc.
Office of the Chief Coroner