Coroner's investigation and inquest
WHO IS THE CORONER?
The coroner is a public officer (physician, attorney or notary) appointed by the government. Under the authority of the chief coroner, the coroner intervenes systematically in the following situations:
- when a death occurs in violent (accident, suicide, homicide) or obscure circumstances, or as a result of negligence;
- when the cause of death is unknown;
- when the deceased’s identity is unknown;
- when the body of a person who died outside Québec is transported into Québec, if the death occurred in violent or obscure circumstances or as a result of negligence, if the deceased’s identity is unknown, or the probable causes of death could not be established;
- when the body of a person who died in Québec must be transported out of Québec;
- when a death occurs in a rehabilitation centre, a penitentiary or a correctional facility, in a security unit within the meaning of the Youth Protection Act (CQLR, c P-34.1), in a police station, daycare, foster family or a health institution where the person was under confinement.
WHO NOTIFIES THE CORONER IN THE EVENT OF A DEATH?
Physicians and police officers are generally the ones who notify the coroner of a death. However, anyone can report an obscure or violent death, or one that was the result of negligence if he or she has reasons to believe that the death escaped the attention of the coroner or the police.
WHAT IS THE CORONER’S FUNCTION?
The coroner must answer the following questions:
- Who died?
- Where and when did the person die?
- What are the probable causes of death?
- What are the circumstances of death?
The coroner’s report is public, and in it he or she may make recommendations to avoid similar deaths in the future.
HOW DOES THE CORONER HELP PREVENT DEATHS?
- By making recommendations following a death
- By inputting a vast database containing documents collected by coroners
- By collaborating with researchers in the field of prevention
- By raising public awareness when releasing certain coroners’ reports
HOW DOES THE CORONER CARRY OUT HIS OR HER DUTIES?
Coroners have two means at their disposal for carrying out their duties: an investigation and a public inquest. The vast majority of deaths reported to the coroner are subject to an investigation and only a few result in a public inquest.
An investigation is a confidential process whereby the coroner gathers the information necessary to fulfil his or her mandate. During an investigation, the coroner:
- is temporarily responsible for the body of the deceased, establishes the deceased’s identity, and may order an autopsy, toxicological analyses or any other scientific expertise deemed necessary. The coroner then entrusts the body to the family;
- gathers information by seizing documents or objects, or requesting that the police question persons to find out the causes and circumstances of the death;
- writes a report that is a public document available to anyone who submits a request;
- submits the report to the chief coroner along with all of the documents that were used to assist in the investigation and that are attached to the report.
A public inquest is not a trial and the coroner is not a judge. Unlike a judge, who rules on disputes between parties and renders a decision, the coroner holds an inquiry to find out the probable causes and circumstances of a death with the goal of preventing other deaths. However, the coroner holds certain powers similar to those of judges, to ensure that the inquest takes place in an orderly and fair manner.
The coroner cannot make a finding of civil or criminal liability in respect of an individual; that is the role of the courts. Instead, the coroner seeks to find out whether changes could be made in order to avoid deaths. If the coroner finds that to be so, it is indicated in his or her report, usually in the form of recommendations made to persons, government departments and bodies, or other organisations.
THE PUBLIC INQUEST
A public inquest is generally ordered by the chief coroner if it is believed that the public would benefit from hearing the information presented to the coroner, or if the chief coroner believes it useful to question under oath, at public hearings, persons who are able to provide information that is important to the inquest. Usually, those hearings take place at a courthouse. Witnesses and experts are then called to testify before the coroner, who conducts the inquest.
A public inquest may deal with one death, or several that occurred in similar circumstances. Like the investigation, it concludes with the preparation of a report that is a public document available to anyone who submits a request.
HOW LONG DOES IT TAKE TO OBTAIN A CORONER’S REPORT?
The coroner must write the report as quickly as possible. However, an investigation requires the efforts of a number of collaborators. Therefore, the coroner must wait for the reports from those collaborators before producing his or her report.
To find out the average time between the reporting of a death and the filing of the coroner’s report, you may consult the Délai de disponibilité d’un rapport de coroner section of our Website.
HOW TO OBTAIN A CORONER’S REPORT
The coroner’s report is a public document. You may obtain a copy by making a request to the Bureau du coroner by email, mail, phone or fax.
You can also make a request online in the Demander un rapport de coroner section of our Website.
The coroner’s report and the autopsy report are two different documents. Whereas the coroner’s report is a public document available to anyone who submits a request, access to the autopsy report is restricted by certain legal conditions. The conditions for obtaining an autopsy report or any other document attached to the coroner’s report are detailed in the Rapports et recommandations section of our Website.
Bureau du coroner (head office)
Édifice Le Delta 2, bureau 390
2875, boulevard Laurier Québec (Québec) G1V 5B1
Toll-free: 1 888 CORONER (267-6637)
Fax: 418 643-6174
To reach a coroner directly, you may consult the Répertoire des coroners on our Website.