Lesson Plan 11: Coroner’s Court

Topic 1: Role of the Coroner

BC Coroners Service

  • Headquarters in Burnaby
  • Province divided into 5 regions
  • 37 full-time Coroners, 71 Community Coroners
  • Variety of backgrounds
  • Not physicians – do not perform autopsies

Responsibilities of Coroner

  • Investigates all unnatural and unexpected deaths
  • Clarifies facts surrounding death for the public record
  • Classifies death
  • Makes recommendations to prevent future death under similar circumstances

Coroners Act SBC 2007, Chapter 15

  • Part I: Definitions
  • Part II: Reporting Deaths
  • Part III: Investigations
  • Part IV: Inquests
  • Part V: Additional Matters Re: Investigations and Inquests
  • Part VI: Death Reviews
  • Part VII: Administration and General Matters
  • Part VII: Transitional Provisions

 Mandatory reporting of deaths: Part II: Sections 2, 3 and 4

  • By anyone
  • By peace officers
  • By institutional administrators

Investigations, Inquests and Death Reviews: Part II: Sections 5 and 6

  • No disturbance of body or wreckage
  • No removal of body from British Columbia

Powers of Investigation: Part III: Section 11

  • Take possession of body and examine
  • Enter and inspect premises where deceased may have been
  • Inspect, copy and seize documents: solicitor/client exception
  • Seize anything believed relevant to the investigation
  • Take charge of wreckage or vehicle to prevent further disturbance of scene
  • Require a person to attend before Coroner and provide information under oath – S 11(1) (h). Specific rights of witness at Inquest granted (S.12)

Coroner’s Report

  • Written report – 1 page Natural and Adult Suicide
  • Public document, available to anyone upon request
  • Identity of deceased, how, where, when and by what means death occurred
  • Narrative of circumstances surrounding death
  • Cause of death and contributing factors
  • Recommendations – where appropriate

Inquests: Part IV

  • Coroner presides over quasi-judicial proceedings
  • Counsel representing parties with participant status
  • Subpoenaed witnesses questioned by counsel
  • Five member jury renders verdict
  • Somewhat similar to court process
  • Deaths in custody of Peace Officers; deaths generating significant public interest, i.e. Charge approval and bail release deaths

Inquest-Rights of Witnesses: Section 35

  • (2) A witness is considered to have objected to answering, but must still answer, any question that may a) incriminate the witness in a criminal proceeding, or b) establish the witness’s liability in a civil proceeding
  • (3) Any answer provided …must not be used or admitted in evidence against the witness in any trial or other proceedings, other than a prosecution for perjury…”

Classifications of Death

  • Natural Death
    • Death primarily resulting from a disease of the body and not resulting from injuries or abnormal environmental factors, for example cancer or heart disease
  • Accidental Death
    • Death due to unintentional or unexpected injury. Includes death resulting from complications reasonably attributed to an accident, for example, a motor vehicle collision, illicit drug overdose, or workplace death
  • Suicide
    • Death resulting from self-inflicted injury, with the intent to cause death
    • Approximately 500 per year, for example, hanging, overdose or firearms
  • Homicide
    • Death due to injury intentionally inflicted by the action of another person
    • Homicide is a neutral term that does not imply fault or blame
    • Approximately 100 per year
  • Undetermined Deaths
    • Death which cannot reasonably be classified as natural, accidental, suicide or homicide, for example, extensive decomposition, skeletal remains, negative findings or suicide vs. accident

Questions Asked by a Coroner

  • Who? (Identification)
    • Visual
    • BCDL/photo ID
    • Tattoos/scars
    • Fingerprints
    • Odontology
    • DNA
    • Circumstantial
  • How? (Medical cause of death)
    • Autopsy by a pathologist
    • Sufficient evidence to determine cause without autopsy, for example, medical records or obvious cause of death
    • Family physician determines cause (non-coroners case)
  • Where? (Location)
    • Where body is found is not necessarily where death occurred, for example, overdoses, or homicides may have occurred places other than where the body was found
  • When? (Time of death)
    • Cannot be accurately, scientifically determined due to many factors affecting postmortem changes
  • By What Means? (Mechanism of death)
    • For example, cause of death is blunt force head injuries then the mechanism of death may be a motor vehicle collision


  • Body
    • a) at the scene
    • b) at the autopsy
  • Scene -- information for pathologist, from family, criminal circumstances, collection of evidence
  • History -- medical/psychiatric, lifestyle, alcohol/illicit drug use

Additional Investigative Resources

  • Police Report
  • Pathologist
  • Toxicologist
  • Pharmanet Records
  • MSP History
  • Social workers
  • Physicians
  • Parole officers
  • WorkSafeBC
  • Transportation Safety
  • Board
  • Public Agencies

2007 Death Cases Statistics

  • Vancouver Metro region – 1,427 cases
  • 984 were natural causes (includes non-coroners cases)
  • 223 accidental deaths
  • 122 suicides
  • 36 homicides
  • 62 were undetermined
  • Most of the cases handled by 5 full-time Coroners, some by Community Coroners

Look at www.pssg.gov.bc.ca/coroners/about/index.htm for the most recent statistics.

Coroner’s Recommendations

  • Approximately 200 recommendations per year
  • Have addressed:
    • Highway and road design
    • Signage, visibility of cross walks
    • Changes to legislation: Graduated Licensing
    • Changes to Child Protection and MCFD practices
    • Hospital standards and practices
  • 71% positive compliance rate