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18.35 |
Dr James Young, Chief Coroner for the Province of Ontario and Assistant Deputy Minister of the Solicitor-General, attended the seminar and described the system in Ontario. |
Background and Structure
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18.36 |
Each of the provinces and territories in Canada has a Chief Coroner or Medical Examiner, who acts as the head of the coronial and death certification system. Ontario has a population of 13 million, spread over an area of one million square kilometres. Much of the population lives in a relatively densely populated area within 100 miles of the US border, but there are vast areas of the province which are sparsely populated. The geography and climate of Ontario present significant challenges to the coronial system. Approximately 60,000 deaths occur each year, and the Chief Coroner's Office investigates and reports on around 20,000 of those deaths. A limited investigation is carried out in relation to a further 10,000 deaths, which occur in nursing homes and residential homes for the elderly. Autopsies are performed in around 7000 cases, which represents a little over a third of those deaths formally investigated. |
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18.37 |
The Chief Coroner has overall responsibility and control over the province-wide system. Authority is delegated to three deputy chief coroners and ten regional supervising coroners, each of whom covers one of the ten geographical areas into which the province's coronial system is divided. There are then about 350 investigating coroners, who attend scenes of death and who are supervised by the regional supervising coroners. All coroners in Ontario are licensed physicians. The investigating coroners have a variety of medical backgrounds, both within and outside hospital, and undertake their coronial duties as part-time additional work for which they are remunerated on a case-by-case basis. Local arrangements are made for rota cover to provide a service 24 hours a day, seven days a week. A system of 'first on call' and 'second on call' is operated, so that a member of staff is always available when needed. Standards in the office require that an investigating coroner should be able to attend at the scene of a death within two to three hours. Despite the antisocial hours, recruiting for the post of an investigating coroner apparently presents no problems. |
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18.38 |
The Chief Coroner is responsible for establishing standards for death investigations. He also directs, controls and supervises death investigations, together with the delivery of forensic pathology services. He offers advice and guidance, both personally and through his deputies and the regional supervising coroners. There is a clear line of authority and accountability within the coroner service in Ontario. |
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18.39 |
There is obvious potential for tension where a doctor in a small, rural community acts as an investigating coroner. He or she may be called upon to investigate deaths of patients of colleagues who are well known to him/her. Investigating coroners are given clear advice about this and are advised to refer a death upwards to the regional supervising coroner, even to the Chief Coroner's Office, if any potential conflict arises. They are also reminded of the importance of considering the 'worst case scenario' in relation to every death, even when dealing with the death of a colleague's patient. |
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18.40 |
It is evident from the documents with which the Inquiry has been provided that the coronial service in Ontario seeks, and, is successful in securing for itself, a high public profile. That profile ensures that the public is aware both of the existence of the service and of the mechanism of investigating deaths about which there is any concern or problem. This acts as a positive encouragement to report deaths about which any concern arises. |
Statutory Framework
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18.41 |
The statutory framework for the Ontario system is contained in the Coroners Act 1990 and the Anatomy Act 1980. |
Objectives
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18.42 |
The motto of the Ontario Chief Coroner's Office is 'We Speak for the Dead to Protect the Living'. In practical terms, the objective of providing protection to the people of Ontario is achieved by implementing high quality death investigation and using the findings to generate recommendations to improve public safety and to prevent further deaths occurring in similar circumstances. The ethos is that no death should be overlooked, concealed or ignored. The Chief Coroner's Office is assisted in achieving its objectives by the high public awareness of the coroner system. Individuals and organisations are encouraged to 'over-report' deaths, even at the risk of time being wasted investigating deaths which might in the event be found to have been entirely natural. |
Deaths Not Reported to the Coroner
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18.43 |
Where a doctor is able and willing to certify the cause of death, the coroner will not become aware of the death until after disposal. A body can be removed to a funeral home only when a certificate as to cause of death has been issued by a doctor or nurse practitioner, or where an investigating coroner has attended and authorised removal of the body. A nurse practitioner can certify the cause of death only in limited circumstances, namely in a case of expected death at home (i.e. not in a nursing home etc.), where the nurse practitioner has had primary responsibility for care, an established diagnosis of a terminal illness has been made and the patient was receiving palliative care. Any registered doctor is authorised to certify the cause of death in an appropriate case, regardless of experience or seniority. There is no formal requirement for a doctor to examine the body in order to certify the cause of death. The standard of confidence for certifying the cause of death is similar to that in Victoria, i.e. the same standard as for diagnosing a condition in a living patient. |
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18.44 |
Although only certain deaths must be reported to the coroner in the first instance, the death certificates in relation to all deaths are ultimately sent to the Chief Coroner's Office. Individual certificates are audited to see if the death should, in fact, have been reported. The ambit of the audit is necessarily limited, since it will detect only errors which are evident on the face of the death certificate. |
Deaths Reported to the Coroner
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18.45 |
The coroner's jurisdiction is limited to 'reportable deaths' and does not extend to all deaths within the geographical jurisdiction. The categories of reportable deaths are wide and contain a provision that 'any death requiring investigation' should be reported. A statutory duty to report deaths to the coroner extends to every person with reason to believe that a person died within a list of particular circumstances, including sudden death, death caused by violence, negligence and other similar categories, as well as some broader categories such as 'death by unfair means'. The duty is subject to a criminal sanction which is rarely imposed. Literature produced by the Chief Coroner's Office acknowledges that the categories of reportable deaths tend to be 'confusing'. |
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18.46 |
The Coroners Act provides that all deaths that occur in residential or in-patient institutions must be reported to the coroner. In practice, this legislative requirement is fulfilled by requiring nursing homes to keep a book of all deaths and to report every tenth death to the coroner. Those deaths are then investigated by means of a paper review. They are then available for audit, or further investigation at a later time if necessary. A death reportable for any other reason must be reported to the coroner in the usual way. An institutional patient death record is completed following any death in a nursing home. The record addresses issues relevant to the need to report, such as whether the death was accidental, sudden and unexpected, and whether the family has raised concerns. The form is then sent to the coroner's office. Where required, the frequency of deaths to be reported by an institution can be altered and, if there are real concerns, the institution can be required to refer every death to the coroner. There are special requirements for deaths in mental hospitals and developmental homes for children. |
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18.47 |
Dr Young told the Inquiry how, on one occasion, his office had a report of a higher than normal death rate at a developmental home. A committee was set up and audited every death which had occurred at the home over a period of five years. This revealed a pattern of withdrawal of medical treatment, leading to death, which could not have been detected in connection with any single death. The coroner's office will carry out similar exercises in relation to a doctor about whom there is concern. |
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18.48 |
Deaths caused or contributed to by medical negligence or malpractice fall within the category of reportable deaths. Hospitals are encouraged to err on the side of over-reporting deaths. Dr Young expressed the view that, if deaths where there was an issue about medical care were not reported, this only produced problems in the future. Hospitals within the province have an audit system in place to assess whether or not a death should be reported to the coroner. Often, nursing staff report deaths. Dr Young observed that they tended to be more reliable than doctors in reporting deaths to his office. |
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18.49 |
A doctor unsure as to whether or not a death should be reported may contact the coroner. In a straightforward case, the coroner may be happy to allow the doctor to certify the cause of death. However, Dr Young made the point that, once an investigative coroner has invested a certain amount of time in a case, it is in his/her financial interests to take the case on, because of the case-by-case basis by which coroners are paid. Coroners are contacted via 'dispatchers' who act as coroner's clerks or intermediaries. The dispatchers are experienced and will be able to answer questions from doctors about, for example, the content of statutory provisions. However, they will not be expected to exercise judgement as to whether or not a death will be accepted by the coroner. Such judgements are left to the coroners themselves. |
Death Investigation
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18.50 |
Following a report of a death, investigating coroners are instructed to attend the scene of death unless there is good reason for not doing so. An investigating coroner should complete a certificate, confirming that s/he has legally seized the body. Investigating coroners are instructed to consider the worst possibility (or 'think dirty') and to liaise with the family in investigating the death. The investigating coroner undertakes and directs a medical investigation and, in a case where there is no suggestion of criminal involvement, will interview witnesses, often in the presence of the police. Extensive written guidance is provided for the investigating coroner. Where there is a hint of criminal involvement, the police take over the investigation, so as to avoid the risk of an investigating coroner tainting the criminal investigation. However, even in such cases, the coroner's office works closely with the police and will provide the necessary medical expertise. |
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18.51 |
If the coroner is minded not to require an autopsy, s/he will undertake a full external examination of the body in situ to ensure that there are no signs of violence. When such an examination is carried out at a person's home, relatives are asked to leave the room and experience has shown that families do not object to such an examination being carried out. There is a practical benefit to families in that, if it is decided that an autopsy is not required, then the body can be released to a funeral home, allowing the relatives to make arrangements for the funeral. The scene, and the body, may be photographed. The coroner has power to seize any evidence necessary for the purposes of his/her investigation. |
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18.52 |
The delivery of forensic pathology is controlled by the Chief Coroner. When a decision is taken that an autopsy is required, the investigating and regional coroners will consider what level of pathology expertise is necessary. Local facilities are available for straightforward cases and, where greater expertise is required, the body is transported to one of the larger regional centres. If necessary, a case can be referred to one of the major centres, such as Toronto or Ottawa, where forensic pathology services are available. In some circumstances, where the circumstances of death are clear, a thorough external examination takes the place of an invasive autopsy, although the use of this technique is restricted to the larger forensic centres. Medical records are obtained in every case which involves a medical issue or where an autopsy is to be performed. The relevant sections of the medical record are photocopied and forwarded with the body to the mortuary. |
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18.53 |
Under the Coroners Act, certain defined categories of family member are entitled to information relating to the investigation of a death. A report will be made available to the family, but will not become a public document. If no inquest or regional review (see 18.57-18.59 below) is carried out, there is usually an opportunity for the family to discuss with the coroner any issues relating to the death. |
Public Investigation of Death
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18.54 |
The number of inquests held in Ontario each year is low in comparison with England and Wales. The aim of the system is to hold a small number of representative inquests which examine issues in detail, as opposed to a larger number of routine inquests, which allow for only superficial examination of the issues and give limited scope for learning lessons in public safety. The statute allows for one inquest to be held into a number of deaths where they have arisen from the same event or from a common cause. Inquests are mandatory in certain categories of case, for example, deaths in custody and construction and mining deaths. Discretionary inquests are held when the public interest requires it. In 2002, there were 54 mandatory inquests, together with 18 discretionary inquests. Included in the statutory list of considerations taken into account when determining whether or not the public interest would be served by the holding of an inquest, is the likelihood that 'recommendations directed to the avoidance of death in similar circumstances' will arise out of the proceedings. Recommendations, typically numbering between 1200 and 1500 each year, are made following both mandatory and discretionary inquests. The public have a right of challenge against a decision not to hold an inquest. Such a challenge is determined by a Government Minister. |
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18.55 |
Inquests in Ontario are presided over by coroners, who do not have formal legal qualifications. The category of coroner that can sit on an inquest is limited to the Chief Coroner, his three deputies, the ten regional supervising coroners and 50 of the most experienced investigating coroners. The more senior members of that group conduct inquests in the most complex cases. Some limited legal training is provided and a detailed inquest manual is provided to assist the coroners while acting in their judicial capacity. Crown attorneys are appointed to act as counsel to the coroner at the inquest hearings and interested parties are often represented by lawyers. |
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18.56 |
Juries sit on all inquests and are responsible for reaching a verdict and making recommendations in the light of the evidence and submissions from interested parties. In many cases, the submissions will include suggested recommendations, which can be adopted in full or in part and supplemented by the juries' own recommendations. The coroner then produces a letter of explanation, setting out the circumstances of death, the procedural history of the inquest, his/her interpretation of the significant parts of the evidence and the jury's rationale for making each of its recommendations. The letter is intended to supplement, not replace, the verdict of the jury. |
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18.57 |
In more complex cases, detailed reviews will be undertaken by standing committees of experts. These include an Anaesthetic Death Review Committee, a Paediatric Death Review Committee, an Obstetrical Care Review Committee and a Geriatric and Long Term Care Review Committee. The committees are chaired by deputy chief or regional coroners and their members are, in general, experts in the field concerned. The Paediatric Death Review Committee has a particularly diverse membership, reflecting the complexity of the topic. The committees review cases at the request of the Chief Coroner. |
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18.58 |
In medical cases, the committees usually look at the hospital notes, the autopsy results and the coroner's investigation to date. One member of the committee will conduct an initial review and the case is then discussed with the whole membership of the committee. A preliminary opinion and set of concerns are formulated and passed on to the regional and investigating coroners. No formal witness statements are taken at that stage. |
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18.59 |
The review is often followed by a meeting between the review committee, the regional coroner and the institution and doctors, or other professionals, involved in the case. A detailed discussion ('a regional review') takes place and this will frequently result in a set of recommendations being agreed. The family is then informed of the results of the review and a decision taken as to whether the case needs to proceed to a public inquest. If such an inquest is thought necessary, the committee member who reviewed the case first is usually retained as an expert witness for the inquest. |
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18.60 |
The advantage of the review committee system is its ability to examine complicated subject matter in a relatively informal manner, more efficiently than the inquest process. Thus, effective recommendations for improvement to systems can be made expeditiously. Dr Young said that the success of the review system was such that hospitals would sometimes report deaths themselves and ask that a review be undertaken, knowing that it would result in useful recommendations. |
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18.61 |
The coroner is under a statutory duty to forward recommendations to any organisation whose failures may have caused or contributed to the death. There is no legal obligation on the organisation to respond. However, in practice, a report is forwarded to the coroner about 12 months later, describing the steps taken to implement the recommended steps. The report is made public and failure to take appropriate preventative measures will receive widespread critical coverage in the press. |
Registration
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18.62 |
The practical aspects of registration are carried out by the funeral director. The certificate of the cause of death, or the coroner's death certificate in cases where the coroner has become involved, is taken to the funeral home. The family will complete a request for burial at the funeral home and the funeral director will take the forms (together with the cremation certificate if relevant) to the registrar, who will register the death. A short form death certificate is available for administrative purposes. This does not include any details of the circumstances of death or cause of death. |
Cremation
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18.63 |
The authorisation of the coroner is required for cremation. Before authorising cremation, the investigating coroner will attend at the funeral home and review the relevant documentation, including the certificate of cause of death and a form filled out by the family. He or she will speak to the funeral director and enquire whether there are any problems associated with the death. The investigating coroner will rarely examine the body. |
Coroners Information System
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18.64 |
Data about deaths is entered into the coroners information system by the local investigating coroner and is subsequently checked by personnel at the offices of the regional coroner and Chief Coroner. The information is used for research projects into public safety issues, such as drinking and driving, or drownings. A Canada-wide database is currently being built which will facilitate the collection of statistical data on the circumstances of deaths. |
Detecting Shipman
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18.65 |
On the basis of the summaries describing the circumstances of four of Shipman's unlawful killings, Dr Young expressed the view that there was some prospect that Shipman's activities would have been detected by the Ontario system. For example, the sudden and unexpected nature of Mrs Grundy's death would probably have caused the friends who discovered her body to contact the police, who in turn would have called the coroner. The investigating coroner, if following procedures correctly, would have spoken to Mrs Grundy's daughter. She would undoubtedly have expressed surprise at the sudden nature of the death. It is most likely that an autopsy would have been ordered with histology. If the cause of death had not been established at autopsy, toxicology would have been ordered. In any event, a blood sample would have been taken, frozen and kept for five years. 'Old age' is not, according to Dr Young, a cause of death which is usually accepted in Ontario. He said that the issue of whether or not the case would have come to the coroner would probably have depended upon the level of concern felt and expressed by the family. |
Comments
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18.66 |
Dr Young expressed the view that the best way of ensuring that the coroner service learned of all relevant deaths was to ensure that it had a high public profile and to make the public aware that there was a mechanism for reporting suspicious deaths. I agree that it is vital that the public has a high degree of awareness of the coroner service, together with the confidence to approach the service in the event of concern. |
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18.67 |
It is evident to me that the Ontario coroner service has strong leadership, together with a positive philosophy, which enables it to meet the practical difficulties presented by the state's geography and climate. The high element of medical expertise available to the service is plainly a strength, as is the emphasis (similar to that in Victoria) on public safety issues and the benefits of learning from deaths which have occurred in the past. I shall suggest that in England and Wales, deaths should be selected for inquest, as in Ontario, on the basis of public interest, with particular emphasis on the prevention of death and injury in future. |
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18.68 |
I also regard as extremely significant the ethos that encourages all concerned to have a high index of suspicion when viewing the circumstances of any particular death. It is essential, if any system of death investigation is to work, that the personnel employed within the system do not approach their task on the assumption that all will be well. If they do, there is a real risk (exemplified by the Shipman case) that they will fail to detect problems which are there to be seen. |
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18.69 |
I was impressed by the robustness of some of the investigative methods, such as attendance at the scene of the death, the taking of photographs and the taking and preservation of blood samples. |
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18.70 |
I was particularly interested in the system by which medical mishaps are investigated, using the services of standing committees of experts. It seems to me that this type of system might well be adopted in England and Wales. It would complement the identification and investigation methods being developed in Victoria, which I also found interesting. |
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18.71 |
I think it highly desirable that England and Wales, like Ontario and Australia, should have a computerised information system. |