Navigating Ontario’s Death Investigation System

March 01, 2018

​By: Kevin Aguiar, Policy Analyst at the Death Investigation Oversight Council

The sudden and unexpected death of a loved one is a devastating stressful event for friends and family members of the deceased. Losing a father, mother, brother, sister, grandparent, son or daughter is a life altering event, regardless of the circumstances. If a survivor of a loved one believes the unexpected and untimely departure is in anyway suspicious, it can magnify the wound ten-fold. 

In such circumstances, the next of kin may be in contact with a wide range of professionals, including police, doctors, lawyers, and support services.  One of these professionals that the family may be in contact with is a coroner and/or forensic pathologist.  Despite the complexity in investigating and determining the cause and manner of death, it is imperative that the system do so in a professional and transparent manner, often in a highly emotional atmosphere. 

Following the need for enhanced oversight to Ontario's death investigation system, the Ontario Government proclaimed the Death Investigation Oversight Council (DIOC) on December 16th, 2010 under the Coroners Act.  DIOC is an independent oversight agency committed to serving Ontarians by ensuring that the Office of the Chief Coroner (OCC) and Ontario Forensic Pathology Service (OFPS) provide death investigations in a transparent, effective and accountable manner. DIOC provides recommendations to the Chief Coroner and Chief Forensic Pathologist including but not limited to financial resource management, strategic planning, quality assurance, performance measures and accountability mechanisms. DIOC also administers a complaints process, if a grieving family or next of kin have a complaint against a coroner, or a forensic pathologist.

Common themes in complaints tend to be about lack of clarity in communication, professional conduct and quality of investigation.

The DIOC Complaints Committee reviews these complaints with a goal of improving the policies and procedures to the death investigation by providing recommendations to the OCC or OFPS.   Since 2010, DIOC has reviewed approximately 36 complaints and has made approximately 21 recommendations back to the OCC and OFPS improving the quality of death investigation services.  In embracing a transparent and open process, DIOC will meet with grieving families who wish to meet in person regarding complaints.

In the past year, DIOC has undertaken an outreach campaign to inform the public of the services provided.  Recently, DIOC was present at the Ontario Association of Chiefs of Police tradeshow. This was a valuable experience for the organization as it made contact with a wide assortment of stakeholders.

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