A coronerís primary
responsibility is to conduct public inquiries into sudden and unexpected
deaths. This responsibility is carried out as directed by the chief
coroner for the province.
Coroners are appointed by
the Lieutenant-Governor in Council upon the recommendation of the attorney
general. In addition to the
a number of other
statutes govern a coronerís scope of activity.
Areas of concern in a
natural death that may initiate a coronerís investigation include
allegations of delay in treatment, misdiagnosis or inappropriate care.
Information from the deceasedís family is often an important part of the
The question of why an
individual died requires careful examination of the circumstances leading
up to the death. To assist the coroner in carrying out this function, a
professional or a team of professionals may be assigned to a case. Areas
of specialized expertise may include pathology, toxicology, forensic
identification, and medical and behavioral investigations.
If youíve been told
that you will be meeting with an investigator from the Coronerís Service,
you are best advised to cooperate. However, since statements made to
anyone may become evidence, there are some things you should do before
agreeing to an interview. Clarify with your manager that you are to meet
with a coronerís investigator and request an opportunity to speak with the
agencyís lawyer. Review the events that occurred, your involvement, any
recording that you made in the chart record and any notes that you may
have made after the event. Remember, absolute honesty is required. Be
prepared to provide information related to the facts as you know them. Do
not draw conclusions, offer opinions about what you think happened or
admit personal responsibility. Finally, call an RNABC nursing practice
consultant for a confidential consultation and written materials that will
help you prepare for the interview.
Unless a coronerís
inquest is called, a coronerís investigation results in a formal, public
document known as a Judgement of Inquiry. The Judgement of
Inquiry is a judicial finding of the coroner. It is the official
record identifying the deceased and the circumstances that led to the
death. The medical cause of death and classification of death (e.g.,
natural, accidental, suicide, homicide or undetermined) is noted. The
report may contain recommendations to prevent future loss of life under
A coronerís inquest
is a quasi-judicial court proceeding. An inquest may be held as a way to
ascertain facts relating to death. It can serve to formally focus
community attention on and initiate community response to preventable
deaths. An inquest is mandatory in all deaths that occur in police
Coroners have the authority
to summon a jury and subpoena witnesses. The presiding coroner of an
inquest has the same authority as a Supreme Court judge to preserve order
and prevent abuse of the inquest process. The role of the coroner is to
organize, control and adjudicate. The coroner also determines which
parties will have standing at the inquest, applies the appropriate rules
of evidence and ensures that the rights of witnesses are protected.
A coronerís inquiry or
investigation is a serious matter and should not be taken lightly. The
coroner is responsible for instructing jury members as to their
responsibility under the
Coroners Act, ensuring that the jury
maintains the goal of fact finding, not fault finding. The jury, comprised
of five members of the community, can also make recommendations. These
recommendations are included along with the presiding coronerís comments
in a public document called the Verdict at Coronerís Inquest.
Although the Coroners
Act provides no power to enforce change, the majority of
recommendations made by coroners and juries are implemented.
Receiving a Summons
When a preliminary
investigation is completed and the Coronerís Service determines that an
inquest will be held, the judicial process is set in motion. Dates and
times are set and witnesses summoned.
If you receive a summons to
a cornerís inquest, notify your employer and ask to discuss the summons.
Ask about support you can expect and ask your manager to arrange a time
for you to talk with the lawyer who will be representing you during the
Do not discuss the events
leading up to the death with anyone other than your employer or the lawyer
who is appointed to support you. In other words, donít talk about this
with co-workers or outside of the work setting.
You may also wish to call
an RNABC nursing practice consultant for a confidential consultation.
RNABC has a number of resources that will assist you in preparing to be a
witness at an inquest.
If you are summoned as a
witness at an inquest, you must attend and give evidence under oath.
Registered nurses employed by health authorities usually receive legal
assistance, before and during an inquest, from lawyers contracted by their
health authorityís liability coverage provider, primarily the British
Columbia Health Care Risk Management Society (BCHCRMS). Other employees
may also have insurance protection and legal services available through
their employer. The lawyer appointed will interview you and, if necessary,
represent you at the inquest. You should also expect to be interviewed by
the lawyer representing the Coronerís Service. These interviews are
important for both you and the lawyers. They will give you an idea of the
proceedings during the inquest, what questions you might expect and
clarify your rights and responsibilities as a witness. The coronerís
lawyer will want to hear about your first-hand knowledge so that the
questioning will bring out all the evidence.
During the Inquest
The coroner is in
charge of the proceedings during an inquest. The coroner generally uses a
lawyer to lead the questioning of witnesses and to provide advice on legal
matters. The coroner sits at the front of the room, the five jurors to one
side facing the public. A court reporter records the proceedings during
the inquest. Witnesses give testimony from a witness stand facing the
public. Lawyers and individuals who have an interest in the outcome of the
inquest may apply to the coroner for ďstanding.Ē This allows them to
ask questions of witnesses. Lawyers granted standing and the lawyer for
the coroner sit at a table in front of the public facing the coroner.
An inquest is a public
hearing and any member of the public may attend. Depending on the nature
of the inquest, and at the coronerís discretion, witnesses may be
excluded from the inquest proceedings until they are required to give
An inquest follows legal
procedures and includes proclamation that the court is open and swearing
in of the jurors. The coroner outlines the information required in the
inquest, gives a brief summary of the facts already known about the death
in question and explains the procedures that will be followed during the
inquest. The coroner, in conjunction with the lawyers, determines the
order in which witnesses are called.
Once all the witnesses have
been called and all evidence has been presented before the court, the
coroner charges the jury to examine all the findings. The jury adjourns to
a jury room to make decisions about who died, when, where and by what
means. The jury may also make recommendations regarding preventing deaths
in similar situations.
The jury makes its
decisions by majority vote. Once the jury has completed its work, the
jurors are ushered into the court and the findings are read out loud and
The record of the inquest
is forwarded to the Office of the Chief Coroner. Those recommendations
regarding practice by registered nurses are forwarded to RNABCís
executive director. Although the recommendations are not legally binding,
RNABC takes them seriously. Depending on the recommendation, RNABC may
initiate any number of strategies as follow up. For example, an RNABC
nursing practice consultant may visit the agency involved and assist in
developing a plan to revise systems to support registered nurses to meet
the RNABC Standards for Nursing Practice in British Columbia. In other
situations, the Association may follow up by publishing recommendations in
Nursing BC for the benefit of all members. Recommendations may also
be incorporated in RNABC publications or programs.
If you are involved in any
aspect of a coronerís investigation or inquest, or if you would like
further information, contact an RNABC nursing practice consultant at (604)
736-6331 (ext. 332) or toll-free 1-800-565-6505, or contact the
Coronerís Service in your community.
The coroner has been
likened to an ombudsman for the dead - that is, the coroner serves to
protect the living by determining the circumstances surrounding an
untimely death. Accordingly, public safety has emerged as a fundamental
interest reflected in the
There are three basic
principles of the B.C. Coronerís Service: fact-finding; providing an
independent service to the people of the community; and serving, first,
the deceased and relatives and friends of the deceased, second, society as
a whole, and third, government agencies and other organizations.
There are two main
programs: investigative and judicial.
As a medical/legal death
investigator, the coroner is responsible for ascertaining the facts
surrounding a death, namely the identity of the deceased and how, when,
where and by what means the deceased died. These facts become a part of
the public record. They serve not only the publicís interest, but also
add to the sum of the knowledge in the fields of forensic science, epidemiologist, public safety and public health.
Section 9 of the Coroners
Act outlines the types of death that must be reported, thereby
initiating the investigative process. The coroner determines the nature
and extent of the investigation required. Deaths of vulnerable citizens,
such as children, the elderly, the indigent, prisoners and the mentally
ill or disabled, are of particular concern to the coroner. A major
function of the Coronerís Service is to ensure that no death is
overlooked, concealed or ignored. The coroner has extensive authority to
secure the scene of the death and take possession of the human remains,
collect information, conduct interviews, inspect and seize documents.
Although anyone may report
a death to the coroner, notification generally comes from police agencies,
hospitals or physicians. If the death appears to be a natural event, the
deceasedís physician is consulted to clarify whether the nature of the
death is consistent with the deceasedís known medical history. If there
are no concerns, the responsibility for signing the Medical Certificate of
Death is waived to the physician and the death is deemed a non-coronerís
Unnatural deaths always
fall within the coronerís jurisdiction. These include suicides,
accidents and homicides. These types of deaths often involve a cooperative
investigation between the coroner and police. Once foul play has been
ruled out, the coroner assumes primary responsibility for determining the
facts surrounding the death. If the death is a homicide, the coroner
retains responsibility for establishing the medical cause of death, while
the police investigate legal culpability.
CORONERS ACT British
Columbia, Canada - Full Act: