McGuinty Government Commits To A Stronger, More Accountable Coroners
TORONTO, Oct. 1 /CNW/ -
Ontario proposes to overhaul its forensic pathology system through the
introduction of new legislation, and to pursue measures to redress past
injustices, in response to the Honourable Justice Stephen Goudge's Inquiry
into Pediatric Forensic Pathology in Ontario.
Justice Goudge released his report and recommendations earlier today. The
McGuinty government called the inquiry in April 2007 - six days after the
chief coroner announced the results of a review into the work of pediatric
pathologist Dr. Charles Smith.
The proposed legislation will, if passed, establish a framework to
strengthen the death investigation system, provide for greater oversight and
accountability and improve coroner and pathology services in Ontario. Guided
by Justice Goudge's recommendations, the legislation will build on the
progress Ontario has made in the past five years to improve the province's
In addition, the Ministry of the Attorney General will:
- Work with justice partners to expedite cases where an injustice is
- Develop a compensation framework for those who suffered injustice.
- Establish a medical/legal review of convictions involving "shaken
"Justice Goudge has provided a roadmap for change to build a stronger,
more accountable coroners system. We intend to move quickly and aggressively
in responding to the report and to build on the work we've already done to
prevent this from happening again," said Community Safety and Correctional
Services Minister Rick Bartolucci
"Justice Goudge's recommendations will strengthen the justice system's
response to child death cases," said Attorney General Chris Bentley
will build on the changes in approach already in place for child homicide
cases. We will also initiate a review of past shaken baby death cases to
determine whether the evolution in scientific opinions affects the validity of
"Over the past few years we've made great strides to strengthen Ontario's
death investigation system. Commissioner Goudge's recommendations will help us
navigate the way forward," said Ontario's Chief Coroner Dr. Andrew McCallum
- Since 2002, pediatric autopsies in Ontario are conducted in one of
four centres (London, Ottawa, Hamilton and Toronto) to ensure they
are carried out where pathology and pediatric expertise are greatest.
- Since 2006, coroners, pathologists, police and other members of the
death investigation team now follow a new and more stringent protocol
when investigating the death of any child under age five.
- Since 2004, all forensic autopsies on criminally suspicious cases,
homicides and cases going to inquest undergo a peer review process to
ensure the quality of the autopsy and the resulting conclusions.
Learn more about Ontario's coroners
Read Justice Goudge's report and recommendations
Disponible en français
ONTARIO'S DEATH INVESTIGATION SYSTEM
The Office of the Chief Coroner for Ontario performs high quality death
investigations and inquests to ensure that no death will be overlooked,
concealed or ignored. The findings are used to generate recommendations to
help improve public safety and prevent deaths in similar circumstances.
Ontario's coroners are physicians trained to investigate sudden and
unexpected deaths, as well as deaths in circumstances requiring further
examination. The purpose of these investigations is to answer five questions:
- Who died?
- How did they die?
- When did they die?
- Where did they die?
- By what means did they die?
Coroners also determine whether a death warrants an inquest - a public
hearing during which evidence is presented to a jury of members of the
community in which a person died. The jury must answer the five questions and
may also make recommendations to avoid deaths in similar circumstances.
Approximately 75 inquests are held each year.
Each year in Ontario, there are approximately 80,000 deaths. The
province's coroners investigate 20,000 deaths per year, 250 of which involve
pediatric deaths (under the age of five).
Ontario has more than 300 coroners. Of these, 65 are also qualified to
THE ROLE OF PATHOLOGISTS
Pathologists are physicians trained in the examination of body tissues
and the impact of disease on tissues and organs. Forensic pathologists have
additional training in matters likely to be presented to the courts. Pediatric
forensic pathology is a particular sub-specialty of pathology focusing on
complex cases involving the death of young children.
Pathologists conduct autopsies when warranted by a coroner, who decides
what is required under the Coroners Act. Autopsies are usually conducted when
a death may have resulted from an accident, foul play or criminally suspicious
circumstances. Each year, coroners warrant more than 7,000 autopsies conducted
by pathologists. Of these, between 200 and 250 involve criminally suspicious
deaths or homicides.
Ontario's chief forensic pathologist reports to the chief coroner and is
responsible for establishing guidelines for the conduct of forensic pathology
in the province.
STRENGTHENING ONTARIO'S DEATH INVESTIGATION SYSTEM
The Office of the Chief Coroner for Ontario has made many operational and
management improvements to strengthen the death investigation system and
- Protocol for investigating pediatric deaths
The Office of the Chief Coroner has implemented a protocol for
coroners, pathologists, police and other members of the death
investigation team to follow when examining pediatric deaths under
two years of age. Since 2006, all deaths of children under the age of
five years are now subjected to this standardized investigation.
- Standardized peer review process
Since 2004, all forensic autopsies on criminally suspicious cases,
homicides and cases going to inquest undergo a peer review process.
This process helps to ensure that all key examinations are performed,
and that the facts and conclusions emerging from the exams are
logical and clearly supported by materials available for any
- Autopsy and death investigation guidelines
Under the direction of the chief forensic pathologist, new guidelines
have been prepared for autopsies on all criminally suspicious and
homicide cases. The guidelines include instructions and information
specific to pediatric autopsies. These guidelines also focus on the
important observations to make at death scenes, what should be
included in reports and how information should be presented, as well
as the essential communication expected among pathologists and other
members of the death investigation team.
- Early case conferences
Since 2002, members of a death investigation team hold early case
conferences following all homicides or criminally suspicious cases
where there are outstanding issues or significant unanswered
questions. The conferences include a senior coroner, the pathologist
who conducted the examination, scientists from the Centre of Forensic
Sciences, police and any other appropriate experts. The conference
ensures that members of the investigative team know the findings of
an autopsy and provides them an opportunity to identify any
outstanding examinations necessary before a pathologist can reach
- Expert pediatric autopsies
Since 2002, pediatric autopsies are conducted in four centres
(London, Ottawa, Hamilton and Toronto). This ensures that the complex
autopsies are conducted at centres where resources and pathology and
pediatric expertise are greatest.
- Professional training for pathologists
A special new course emphasizing the importance of fair and balanced
testimony has been developed for pathologists who provide expert
testimony in court.
- Coroner's reviews
The Chief Coroner's Review Process allows the chief coroner to
appoint a panel to review the work of a coroner should serious
concerns be raised about that work.
As well, child deaths are the exclusive focus of two new expert
committees in the chief coroner's office. They are the Deaths Under
Five Committee, which reviews the deaths of all children under five
and the Pediatric Death Review Committee, which reviews complex cases
where children of any age have died.
- Management and operational review
In the fall of 2007, the Office of the Chief Coroner engaged an
external consulting firm to review its quality assurance processes
and practices in the areas of strategic planning, human resources,
leadership and support and internal communication. The review was
submitted to the Goudge Inquiry, and the chief coroner's office is in
the process of acting on its recommendations.
Resources and Infrastructure
- Increased funding
The government has nearly doubled annual funding to the Office of the
Chief Coroner from approximately $20 million in 2003-04 to more than
$36 million in 2008-09. The additional funds have been used to
improve remuneration for investigating coroners and pathologists, as
well as to meet other increases in the operational costs of the chief
- A new Forensic Services Complex
The ministry is in the planning stages of a new Forensic Services
Complex that could put the Office of the Chief Coroner and the Centre
of Forensic Sciences on one site. The proposed complex would provide
the space and advanced technology to support a growing population and
keep pace with the demands of the justice sector.
- Central dispatch for coroners
A three-month pilot program to evaluate the effectiveness of a
central dispatch system will begin in Halton Region this fall. This
initiative addresses the need for proper communication among regional
supervising coroners and investigating coroners so that regional
offices are aware of all active cases within their jurisdiction.
CHANGES TO CROWN PRACTICE IN CHILD HOMICIDE CASES
As well as the improvements made by the chief coroner's office, the
Ministry of the Attorney General has also implemented a number of initiatives
to improve the way it handles child homicide cases, including:
- Appointing a nine-person Child Homicide Resource Team to provide
advice to Crowns at all stages of a child homicide prosecution.
- Developing a database to better track child homicide cases and the
pathologists involved in those cases.
- Enhancing Crown training and education on pediatric forensic
pathology issues and assessing expert evidence.
The Ministry of the Attorney General has retained the Honourable Patrick
LeSage, former chief justice of the Superior Court of Justice, to advise the
Criminal Convictions Review Committee.
Mr. LeSage and the committee provide advice to Crowns on trends emerging
from child homicide cases and other cases.
FOR MORE INFORMATION
Learn more about the Office of the Chief Coroner of Ontario
Disponible en français
For further information:
For further information: Laura Blondeau, Ministry of Community Safety
and Correctional Services, Minister's Office, (416) 325-4973; Stuart
McGetrick, Ministry of Community Safety and Correctional Services,
Communications Branch, (416) 325-9686; Sheamus Murphy, Ministry of Attorney
General, Minister's Office, (416) 326-1785; Brendan Crawley, Ministry of
Attorney General, Communications Branch, (416) 326-2210