Purpose of an inquest
We may hold a public coroner’s inquest to determine the facts and circumstances of a death. A coroner presides over this court-like proceeding.
A 6-member jury answers the following questions about the death:
- Who was the deceased?
- Where did they die?
- When did they die?
- What was the medical cause of death?
- What was the manner (natural, accidental, suicide, homicide, undetermined) of death?
The chief coroner will order a coroner’s inquest:
- when mandatory under section 11 of the Coroners Act, for example if the deceased was in RCMP custody or if a peace officer dies; or
- if the coroner has reason to believe a death occurred as a result of:
- unfair means,
- misconduct, or
Inquests are not:
- an adversarial process;
- a trial or a process for discovery; or
- directed by personal, political or philosophical agendas.
Attending and participating
Attending an inquest
Inquests are open to the public and media.
While an inquest is not a criminal court of record, it is a court process. Anyone attending an inquest must demonstrate appropriate behaviour, dress and demeanor.
You are not permitted to use cameras and recording devices in the courtroom. The inquest proceedings are recorded and can be transcribed at a cost.
Media can apply to the coroner at the beginning of an inquest to use devices and social media.
Participating at an inquest
A person who wishes to take part in an inquest may apply to the chief coroner. This is called applying for standing.
The coroner will accept applications for standing in writing any time before the conclusion of an inquest. They may grant standing before the start of the daily proceedings.
You may apply for standing if:
- you're a person or agency with substantial or direct interest in an inquest;
- potential recommendations from the inquest may affect you; or
- you want to take an active and official part in the proceedings.
It's the coroner's decision which parties they grant standing to. The coroner must find that the party is both substantially and directly affected by the inquest.
Additional information for participants
A person granted standing in an inquest is included in the inquest preparation processes and proceedings. They will have the opportunity to examine and cross-examine witness evidence. Persons with standing may request to summon any witness to testify at the inquest.
It is not necessary for persons with standing to hire a lawyer, although they may choose to do so at their own cost.
The coroner's service will not pay for travel, accommodation, or per diem costs for participants unless the coroner has summoned them.
If the coroner summons a person or agency, they will be provided accommodation, travel, per diem and witness fees (as applicable).
The inquest process
What happens during an inquest?
- Before the inquest, the Sheriff’s Office summons a panel of potential jurors.
- The coroner asks potential jurors questions to determine they’re unbiased and suitable for the inquest.
- The coroner swears the jury in.
- On the first day of inquest, the coroner starts with opening remarks, including a brief overview of the death.
- The coroner explains to the jury their role and responsibilities and that the inquest is a fact-finding proceeding that will assign no fault or blame.
- The coroner calls the 1st witness and all parties will have an opportunity to ask them questions.
- The coroner provides a summary of the evidence after all witnesses and evidence has been presented.
- The jury deliberates to answer the questions: who, what, when, where and how, and, if appropriate, makes recommendations.
- The jury completes their deliberations.
- The coroner reads the jury’s verdict and any recommendations into the record.
- The jury may make recommendations that aim to prevent similar deaths from happening in the future. Recommendations made by a coroner’s inquest jury are not legally binding. However, the vast majority of recommendations are voluntarily implemented.
- The chief coroner is then tasked with ensuring the implementation of recommendations.
- The Department of Justice will post the verdict and any recommendations to the government website for public access.
Evidence and witnesses
The coroner and coroner’s counsel:
- decides what evidence to present; and
- presents all relevant information to the jury for consideration.
For the coroner to allow a witness to present evidence they must meet all the following requirements:
- they must prove they're qualified through experience and training;
- the coroner must verify the witnesses’ credentials; and
- all persons with standing must agree that the person is indeed qualified to provide expert opinions.
The coroner has the discretion to allow or not allow testimony. They can choose evidence in a few ways:
- All parties with standing decide the information, facts and evidence required to present the issues to the jury.
- Families of the deceased provide input on witnesses, expert evidence and the issues they would like addressed.
- Persons with standing are provided a compilation of all information gathered from the investigation.
Once the coroner is satisfied with the presentation of evidence, they may limit cross-examination of a witness.
Both the Canada Evidence Act and the Canadian Charter of Rights provide for protection of witnesses relating to giving testimony.