Justice - Coroners Service
Investigations and Inquests – What Occurs
All deaths that are unnatural, unexpected, unexplained or unattended must be
reported to a coroner. Upon receiving a report of a death, the coroner
begins an investigation, which ends in one of three ways:
If the coroner determines that the death was due to a natural disease
process, the Coroner will contact the personal physician of the deceased to
obtain information on medical history. If it is confirmed that the death is
natural, the responsibility for completing the medical death certificate
remains with the physician.
An investigation is conducted and a coroner’s report is written. When a
death is reported to the Coroner, he/she has the authority to collect
information, conduct interviews, inspect and seize documents and secure the
Upon conclusion, the facts as determined by the investigation, are released
on a report. It sets out the coroner’s findings, including a cause of death
and whenever possible, recommendations to prevent future deaths. For a copy
of the coroner's report contact the regional coroner office in your area.
Note: An investigation may be reopened on the grounds that new evidence has
arisen or has been discovered. An application to reopen an investigation is
made by writing a letter to the Chief Coroner outlining the new evidence.
An inquest is held and a Verdict at Inquest is written. Inquests are formal
court proceedings, with a five-person jury, held to publicly review the
circumstances of a death. The jury hears evidence from witnesses under
subpoena in order to determine the facts of the death. The presiding coroner
is responsible to ensure the jury maintains the goal of fact finding, not
An inquest is held if the coroner determines that it would be beneficial in:
addressing community concern about a death, assisting in finding information
about the deceased or circumstances around a death and or drawing attention
to a cause of death if such awareness can prevent future deaths.
An inquest is mandatory if the deceased was in
the care or control or a police officer or in a police lock-up at the time
of their death unless the Chief Coroner exercises the discretion provided
under Section 18 of the
Upon conclusion, a written report, the Verdict
at Inquest is prepared. It includes the classification of the death and
whenever possible recommendations of the jury on how to prevent a similar
death. The Verdict at Inquest for some inquests is posted on the
Inquest Schedule and Outcomes page. For a
copy of the Verdict at Inquest that is not posted, contact the regional
coroner office in your area.
Media Guide to attending Inquests
The Media Information Guide to a Coroner's Inquest is for members of the
media who are attending a coroner’s inquest.
The intent of this information package is to:
Provide an overview of coroner’s inquests in general
Provide guidelines and requirements for the media
Allow for the regular, daily work of the local courthouse, or other
venue, to continue without disruption
Download the Media Information Guide to a Coroner's Inquest.
For inquest schedule
Inquest Schedule and Outcomes
Schedule, Jury Findings and Verdicts
News and Updates
Child Death Review Unit