The research article by Walter and colleagues1 highlights the work of coroners, but the results are not generalizable to Canada, or Ontario, in particular.
The authors did not attempt to analyze factors predicting coroners’ decisions outside of Australia. In contrast, coroners in Australia are barristers, whereas coroners in Ontario are physicians. This is one reason why Ontario’s inquest data differ significantly from those of Walter and colleagues.1
Ontario conducts fewer inquests than Australia per year and per capita. Ontario’s system reviews all investigated deaths for potential inquest, guided by a structured review process and the Ontario Coroners Act. A discretionary inquest may be called where a coroner’s jury may be able to render a verdict that could not be reached by investigation alone; where the jury could make previously unappreciated recommendations; and/or where the public interest may be served via a public hearing. However, the relative merits must be carefully considered in each case.
The Office of the Chief Coroner2 keeps data on a number of aspects of inquests. Each year from 2000 to 2009, an average of 70 inquests were held in Ontario (59 mandatory and 11 discretionary inquests), providing an average of 493 recommendations per year (unpublished data). In contrast to Australia, Ontario conducts few inquests into pediatric deaths or those due to complications of medical care. Lay juries are challenged by complex medical issues. Hence, such matters are best dealt with by multidisciplinary expert review committees, individual case-based recommendations or regional coroner reviews.
Physician coroners allow for more efficient inquests by applying medical knowledge. Death investigation, in our view, is and ought to be based in medicine supplemented by the law.