Report on 2013 Inquests

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Office of the Chief Coroner

Report on 2013 Inquests

March 2016

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Message from the Chief Coroner
Introduction
Verdicts and Recommendations
2013 Summary
Comprehensive Report on 2013 Inquests
Evaluation of Responses
Summary of Inquests (2013) – Based on Type of Inquest
Summary of Inquests – 2013
Historical Analysis of Inquests 2007 – 2013
Rates of Responses to Recommendations 2007 – 2013
Analysis of Responses to Recommendations from Individual Inquests


Message from the Chief Coroner

The inquest process is a cornerstone of Ontario’s death investigation system and is considered an important contributor to enhancing public safety in our province.  It is perhaps the most well-known mechanism to advance public safety, but it is by no means, the only mechanism.  The Office of the Chief Coroner has six standing committees that review deaths under certain circumstances for the same purposes as an inquest.  In fact, public safety recommendations may arise at the case level following investigation of the circumstances of an individual death.  Given that Ontario has North America’s biggest and busiest death investigation system with approximately 16,000 death investigations per year, other methods to review deaths must be utilized however, the inquest is considered the pinnacle of our system and is well regarded as an effective way to bring issues forward for meaningful dialogue and thoughtful consideration.

I am pleased to present the 2013 Report on Inquests.  In the calendar year 2013, we conducted a total of 33 inquests, a decrease of 4 from 2012.  As in years past, the vast majority of the inquests conducted were mandatory in nature with two being discretionary.  Total inquest recommendations submitted by juries were 271 with the range being 0 to 104 for the largest inquest which examined the circumstances of the death of Ashley Smith.  Ms. Smith died in federal custody and the inquest examined, among other issues, the effect of long-term solitary confinement on the inmate population.  This inquest was of interest to people across Canada and to enable their ability to observe the proceedings, the Office of the Chief Coroner was pleased to be able to webcast it.

For 2013, the average response rate to recommendations from discretionary inquests remains a steady 65% or greater.  The average response rate for all mandatory inquests was 69%, a decrease of 11% from 2012.  The exception to this was mining-related inquests which saw a 14% increase in response rate.

The following report contains additional statistical data on Ontario’s inquest system with only a few highlights detailed above.  If there is data that is not presented here, but would be desired, all members of the public are invited to contact our office.  Contact information is contained on the back page of the report.

To conclude, I would like to take this opportunity to thank the staff members of the Inquest Unit for their continued support; our inquest coroners and coroner’s counsel for their dedication and commitment to the process, and our coroner constables and investigators for their diligent assistance and expertise.

Dirk Huyer, MD
Chief Coroner for Ontario


Introduction

What is an Inquest?

An inquest is an open and public hearing conducted by a coroner before a jury of five community members. Inquests are held in the public interest for the purpose of informing the public about the circumstances of a death. No one is on trial at an inquest and the jury cannot make findings of guilt or blame, or imply responsibility on any person(s) or agency, organization or other entity. The inquest is intended to make the facts of a death public and to identify, if possible, how similar deaths might be prevented.

The purpose of an inquest is to answer the following five questions:

  • Who was the deceased?
  • Where did the death occur?
  • When did the death occur?
  • How did the death occur (the medical cause)?
  • By what means did the death occur? (i.e. manner of death)

“By what means” or “manner of death” includes the following categories: Natural, Accident, Homicide, Suicide, and Undetermined.

It is hoped the jury will make recommendations that if implemented, may prevent future deaths in similar circumstances, thereby advancing public safety.

Types of Inquests

There are two types of inquests: mandatory and discretionary.

Mandatory inquests: Under the Coroners Act, an inquest must be called if the death occurred;

  • accidentally, at a construction worksite, mining, pit or quarry site.
  • by non-natural means while in a correctional facility.
  • while detained by or in the actual custody of a peace officer.
  • in a psychiatric facility where the use of mechanical restraints were a factor in the death.
  • involving a child under  circumstances  described in Section 72 Child and Family Services Act.

Discretionary inquests: Discretionary inquests are called when it is believed there may be systemic issues that, when explored through the inquest process, could advance public safety. Discretionary inquests can also be called to correct misinformation and when there is new information that could benefit segments of the public who may be in a position to effect change.

There are several factors that a coroner takes into account when deciding whether to hold a discretionary inquest. Consideration is given to whether the answers to the five questions are known and whether there is public benefit to have an open and full hearing of the circumstances of a death.

An inquest allows juries to make recommendations with the goal to inform change to prevent deaths in similar circumstances. This preventative function is an important aspect of inquests because it encourages changes that can result in a safer environment for the people of Ontario. Recommendations from inquests have informed changes to legislation (e.g. graduated licensing and labour laws), policy (e.g. how the police and courts administer justice), procedures (e.g. how we protect children and how safe medical practices are encouraged) and product development (e.g. safety mechanisms for motorized vehicles and other consumer goods).

There is no legislated time limit between the date of death and when an inquest is held.


Verdicts and Recommendations

Following the inquest, organizations and/or agencies are notified that there are recommendations pertinent to them and are provided with those as well as the verdict and a short summary of the circumstances of the death and rationale for the recommendations.  Recipients are asked to respond to the Office of the Chief Coroner within one year of receipt. While they are under no legal obligation to implement recommendations or respond, most organizations and agencies provide a response.


2013 Summary

The following statistics reflect inquests for the 2013 calendar year:

  • 33 inquests were held
  • the average length of an inquest was 7.5 days
  • 6% of the inquests conducted were discretionary
  • 94 % of the inquests conducted were mandatory (custody, construction and mining)
  • 52 % were deaths that occurred either in police custody (41%) or individuals detained in a corrections or mental health facility (59%)
  • 36% were construction
  • 6% were mining deaths

Of the deaths that were the subject of an inquest in 2013:

  • 0% were natural
  • 67% were accidents
  • 27% were suicides
  • 6% were homicides
  • 0% were undetermined
  • 100% of the construction inquests and mining inquests were accidental deaths

Recommendations and responses:

Of the 33 inquests, a total of 271 recommendations were made. The number of recommendations varied from zero recommendations in 24% of the inquests, to as many as 104 recommendations for the largest inquest.

Of the organizations and agencies that received recommendations, 69% provided a response.

Review of the responses received indicated:

  • 9% have been implemented
  • 8.2% will be implemented
  • 1% had alternates implemented
  • 18.4% are under consideration
  • 30.8% noted the content or intent of the recommendation was already in place
  • 0% reported unresolved issues
  • 8.7 % rejected the recommendations without providing a reason
  • 8 % did not apply to the agency assigned*
  • 1.2% were rejected due to flaws
  • 14.3% no response was received from the organization

*In some instances, the recipient will advise the Office of the Chief Coroner of another organization which may be in a better position to respond to the recommendation. The recommendation is then redirected to the suggested recipient.


Comprehensive Report on 2013 Inquests

This chart provides an overall summary of the inquests that took place in 2013, including the number of recommendations stemming from the inquest, the type of inquest (mining, custody, construction or discretionary), how the person died (accident, suicide, natural or homicide), the inquest length, how many organizations received recommendations and the recipient response rate.

Table A: Summary of Inquests

Table A

#

Inquest Number

# Recs

Inquest Type

By  What Means

# Days

# Orgs. Asked To Respond

% Responses

1

2013-01

3

Mining

A

2

2

100

2

2013-02

8

Cust

S

3

1

100

3

2013-03

1

Cust

A

2

1

100

4

2013-04

14

Mining

A

3

8

62.5

5

2013-05

1

Cust

S

2

2

50

6

2013-06

2

Const

A

3

1

0

7

2013-07

3

Disc

A

3

2

50

8

2013-08

1

Cust

A

1

1

100

9

2013-09

9

Cust

S

10

1

100

10

2013-10

8

Const

A

3

2

50

11

2013-11

0

Cust

A

2

0

N/A

12

2013-12

9

Cust

H

8

3

66.7

13

2013-13

6

Const

A

2

4

50

14

2013-14

0

Cust

S,S

1

0

N/A

15

2013-15

7

Const

A

2

2

50

16

2013-16

0

Cust

S

1

0

N/A

17

2013-17

0

Cust

S

1

0

N/A

18

2013-18

0

Cust

S

1

0

N/A

19

2013-19

21

Cust

A

17

3

66.7

20

2013-20

9

Const

A

3

3

100

21

2013-21

2

Const

A

2

1

100

22

2013-22

9

Disc

A

6

7

100

23

2013-23

1

Const

A

3

1

0

24

2013-24

6

Const

A

4

1

100

25

2013-25

23

Cust

S

10

8

75

26

2013-26

0

Cust

A

5

0

N/A

27

2013-27

0

Const

A

1

0

N/A

28

2013-28

4

Cust

A

4

5

100

29

2013-29

1

Const

A

1

1

100

30

2013-30

12

Cust

S

9

1

0

31

2013-31

0

Const

A

2

0

N/A

32

2013-32

104

Cust

H

128

3

33.3

33

2013-33

7

Const

A

2

3

100

Note:  In some cases, the number of responding organizations exceeded the actual number of organizations asked to respond. This occurs as initial recipients may advise the Office of the Chief Coroner of another organization which may be in a better position to respond to the recommendation. The recommendation is then redirected to the suggested recipient.

In addition because individual recommendations are often directed to more than one organization, the total number of responses may be greater than the total number of recommendations.

Cust = custody; Const = construction; Disc = discretionary; N = natural; A = accident; S = suicide; H = homicide; U = undetermined


Evaluation of Responses

Organizations and agencies are asked to respond individually to recommendations and are requested to self-evaluate their responses with the codes listed below. Responses that are not “self-analyzed” are reviewed by staff at the Office of the Chief Coroner and assigned response codes.

Responses to jury recommendations are evaluated according to the following codes:

  • Recommendation has been implemented.
  • Recommendation will be implemented.
  • Alternative recommendation has been implemented.
  • Alternative recommendation will be implemented.
  • The recommendation is under consideration.
  • There are unresolved issues with the recommendation that need to be addressed.
  • The recommendation is rejected.
  • The recommendation is rejected due to flaws.
  • The recommendation is rejected due to lack of resources.
  • The recommendation did not apply to the agency assigned.
  • There was no response to the recommendation.
  • The response could not be evaluated (e.g.: response was vague, response did not address stated recommendation, etc.)
  • Content or intent of recommendation already in place


 

Summary of Inquests (2013) – Based on Type of Inquest

Summary of Inquests (2013) – Based on Type of Inquest

Type

Total # of Recs

% of Total Recs

Total # of Inquests

% of Total Inquests

Avg # of Recs per Inquest

Avg % Response Rate*

Total # Days in Inquest

Avg # Days in Inquest

Discretionary

12

4

2

6

6

75

9

4.5

Custody

193

71

17

52

11

72

205

12

Construction

49

18

12

36

4

62

28

2

Mining

17

6

2

6

9

81

5

2.5

Total

271

100

33

100

8

69

247

7.5

 *Note: the number of organizations that were asked to respond versus the number of organizations that did respond (as a percentage).

Figure 1 - Percentage of Inquests by Type - 2013

Figure 1 1. Percentage of Inquest by Type – 2013. (Page 13) This image is a pie chart which shows the percentage of inquests by type. Construction 36%, Custody-52%, Mining-6%, and Discretionary-6%.


Summary of Inquests 2013

Figure 2 - Average Number of Recommendations, Inquest Type – 2013

Figure 2: This image is a bar chart which displays the average number of recommendations by inquest type. Construction-4, Custody-11, Mining-9, and Discretionary-6.

Figure 3 - Percentage of Total Recommendations, Inquest Type - 2013

Figure 3 This image is a pie chart which displays the percentage of total recommendations by type of inquest. Construction-18%, Custody-71%, Mining-6%, and Discretionary-5%.

Figure 4 - Average Number of Days per Inquest - 2013

Figure 4 This image is a bar chart which displays the average number of days per inquest.  Discretionary-4.5, Custody-12, Construction-2, and Mining 2.5.

Figure 5 - Average Rate of Agency Response, Inquest Type - 2013

Figure 5 This image is a bar chart which displays the average response rate by type of inquest. Discretionary-75%, Custody-72%, Construction-62%, and Mining-81%.

Figure 6 - Percentage of Inquests, Manner of Death - 2013

figure 6 This image is a pie chart which displays the percentage of inquests by manner of death. Natural-0%, Accident-67%, Suicide-27%, Homicide-6%, Undetermined-0%.


Historical Analysis of Inquests 2007 – 2013​

Historical Analysis of Inquests 2007 – 2013​

    Totals

2007

2008

2009

2010

2011

2012

2013

Total Number of Inquests

59

76

72

58

34

37

33

Number of Construction Inquests (Mandatory)

16

17

18

18

10

11

12

Number of Custody Inquests (Mandatory)

35

54

49

33

17

16

17

Number of Mining Inquests (Mandatory)

4

2

4

5

1

1

2

Total Number of Mandatory Inquests

55

73

71

56

28

28

31

Total number of Discretionary Inquests

4

3

1

2

6

9

2

Figure 7 - Total Number of Recommendations, 2007 - 2013

Figure 7 This image is a bar chart which displays the total number of recommendations for each year from 2007 to 2013. 2007-361, 2008-423, 2009-354, 2010-282, 2011-355, 2012-316, 2013-271.

Figure 8 - Average Number of Recommendations per Inquest, 2007 – 2013

Figure 8 This image is a bar chart which displays the average number of recommendations per inquest per year from 2007 to 2013. 2007-6.1, 2008-5.6, 2009-4.9, 2010-4.9, 2011-10.4, 2012-9.3, 2013-8.2.

Figure 9 - Average Number of Recommendations Per Discretionary Inquests, 2007–2013

Figure 9 This image is a bar chart which displays the average number of recommendations per Discretionary inquest from 2007 to 2013. 2007-25.2, 2008-8.7, 2009-7, 2010-30.5, 2011-22.3, 2012-19, 2013-6.

Figure 10 - Average Number of Recommendations Per Custody Inquests, 2007 – 2013

Figure 10 This image is a bar chart which displays the average number of recommendations per Custody inquest from 2007 to 2013. 2007-3.6, 2008-5.1, 2009-4.4, 2010-3.5, 2011-9.3, 2012-6.3, 2013-11.35.

Figure 11- Average Number of Recommendations Per Construction Inquests, 2007 – 2013

Figure 11 This image is a bar chart which displays the average number of recommendations per Construction inquest from 2007 to 2013. 2007-7.5, 2008-5.6, 2009-4.6, 2010-4.2, 2011-4, 2012-2.6, 2013-4.

Figure 12 - Average Number of Recommendations per Mining Inquests, 2007 – 2013

Figure 12  This image is a bar chart which displays the average number of recommendations per Mining inquest from 2007 to 2013. 2007-7.5, 2008-14, 2009-11.8, 2010-5.4, 2011-21, 2012-15, 2013-8.5.

Figure 13 - Average Number of Days Per Inquest, 2007 – 2013

Figure 13 This image is a bar chart which displays the average number of days per inquest from 2007 to 2013. 2007-5.2, 2008-3, 2009-3, 2010-3.75, 2011-6, 2012-6, 2013-7.5.

Figure 14 - Inquests with No Recommendations, Inquest Type, 2007 – 2013

Figure 14 This image shows that the number of inquests with no recommendations has generally  decreased across all types from 2007-2013

Figure 15 - Inquests with No Recommendations, Totals, 2007 – 2013

Figure 15 2007: Total=14, Percentage=24 2008: Total=21, Percentage=28 2009: Total=26, Percentage=36 2010: Total=19, Percentage=33 2011: Total=7, Percentage=21 2012: Total=4, Percentage=11 2013: Total=8, Percentage=24


Rates of Responses to All Recommendations 2007 – 2013

Rates of Responses to All Recommendations 2007 – 2013

  

2007

2008

2009

2010

2011

2012

2013

Rates of responses to recommendations (% of organizations asked to respond, that did respond)

76%

75%

79%

83%

75%

80.6%

69%

Discretionary Inquests

65%

67%

67%

69%

69%

80%

75%

Mandatory Inquests (total)

73%

78%

83%

84%

76%

80%

68%

Custody

85%

88%

79%

93%

83%

86%

72%

Construction

77%

79%

88%

75%

65%

69%

62%

Mining

56%

67%

83%

75%

100%

67%

81%

Note:  Percentages may not equal 100 due to rounding off.



 

Analysis of Responses to Recommendations from Individual Inquests

Historical and jury verdicts and recommendations of individual inquests prior to January 2014 are available on The Canadian Legal Information Institute (CanLII) website.

Inquests completed as of January 2014 are available on the Ontario Ministry of Community Safety and Correctional Services website in the Death Investigations section. Verdict explanations (which contain the verdict, recommendations and the coroner’s summary of evidence) as well as selected inquest rulings will continue to be published on the CanLII website.


Contact

Office of the Chief Coroner
25 Morton Shulman Avenue
Toronto, ON M3M 0B1
416-314-4000
E-Mail: occ.inquiries@ontario.ca