Department of Justice

Coroner's Office

Coroner's Inquests

What is a coroner's inquest?

Frequently asked questions  

Inquest protocol and process


  • A coroner’s inquest is a quasi-judicial (court-like) proceeding whereby the facts and circumstances of a particular death are publically aired. 
  • A coroner presides over the inquest and a six-member jury are tasked to answer the following questions:
    1. Who was the deceased?
    2. Where did he or she die?
    3. When did he or she die?
    4. What was the medical cause of death?
    5. What was the manner (natural, accidental, suicide, homicide, undetermined) of death?
  • The jury may make recommendations that aim to prevent similar deaths from occurring in the future. Recommendations made by the coroner’s inquest jury are not legally binding; however, the vast majority of recommendations are voluntarily implemented.

 Inquest Facts:  Inquests are NOT:
  • Inquests are open to the public and media
  • Must not interfere with an ongoing police investigation
  • There is no time limit between the date of death and the convening of an inquest
  • An adversarial process
  • A trial or a process for discovery
  • Directed by personal, political or philosophical agendas


When is an inquest into a death ordered?
What is standing and how do I apply?
What is the timeline for application for standing?
What financial provisions are made for travel expenses for families or others?
Who decides what can be presented as evidence and what governs decisions about admissible evidence?
Who decides what facts will be presented to the jury?
Who decides what expert witnesses are called to provide evidence?
When are parties with standing provided inquest materials?

When is an inquest into a death ordered?

There are two types of inquests: mandatory and discretionary. 

Mandatory inquests are those that are required under section 11 of the Coroners Act: “If a prisoner in a prison, jail or lock-up or in the custody of the Royal Canadian Mounted Police or a peace officer dies and notice of the prisoner’s death is given to a coroner by the warden or other official or person in charge or in whose custody the prisoner was, the coroner shall issue a warrant in the prescribed form and hold an inquest on the body.”

Discretionary inquests are those that are provided for under section 9(1) of the Coroners Act: “If a coroner, after investigation, has reason to believe that a deceased person came to their death as a result of violence, misadventure, or unfair means or as a result of negligence, misconduct or malpractice on the part of others or under any other circumstances that require an inquest, the coroner may hold an inquest.”


What is standing and how do I apply?

Standing is a designation that allows persons or agencies with substantial or direct interest, or who may be directly affected by any potential recommendations, to take an active and official part in the proceedings.

Persons granted standing are included in the inquest preparation processes and proceedings, and have the opportunity to examine and cross-examine witness evidence. Persons with standing may request to summons any witness to testify at the inquest.

It is not necessary for persons with standing to be represented by a lawyer in order to ensure their full and complete participation at inquest, although they may choose to be represented by a lawyer at their own cost.

A person who wishes standing at an inquest may apply in writing to the chief coroner. 


What is the timeline for application for standing?

Persons who wish to request standing at an inquest may apply in writing to the chief coroner at any time prior to the conclusion of an inquest and may be granted standing prior to the commencement of the daily proceedings.

It is the decision of the presiding coroner which parties are granted standing at inquest and the coroner must find that the party is both substantially and directly affected by the inquest.


What financial provisions are made for travel and per diem expenses for families or others?

The Coroner's Service does not pay for travel, accommodation, or per diem costs (daily expenses) for persons or agencies with or without standing. 

If a person or agency is called or summoned by the coroner, witnesses are provided accommodation, travel, per diem and witness fees as applicable.

Who decides what can be presented as evidence and what governs decisions of what is admissible as evidence?

The role of coroner’s counsel (lawyer) at an inquest is to assist the presiding coroner in making legal decisions, leading evidence, and entering exhibits. Counsel represents the coroner, not the deceased’s estate, nor the interests of other parties. 

The coroner has the duty and discretion to disallow inadmissible, prejudicial, repetitious other otherwise improper testimony. The coroner may reasonably limit further cross-examination of a witness if he/she is satisfied that the facts relating to the evidence have been fully and fairly disclosed.

There is a protection of witnesses relating to testimony provided in the Canada Evidence Act and the Canadian Charter of Rights.    


Who decides what facts will be presented to the jury?

All relevant information related to the death will be presented to the jury for their consideration.

The coroner makes the decision with counsel on what is presented, but there is discussion with all the parties with standing during the pre-inquest meetings to identify relevant issues and what information, facts and evidence is required to properly present the issues to the jury.

Through a person with standing, families of a deceased are involved throughout the inquest planning process and are asked to provide input regarding what witnesses should be called, what expert evidence they see as relevant and necessary, and what issues they would like addressed. 

Persons with standing are provided disclosure of information prior to inquest, which is a compilation of all the information gathered from the investigation.  


Who decides what expert witnesses are called to provide evidence? 

Expert witnesses must be qualified through experience and training in order to provide an opinion or evidence. 

Before a witness can provide an opinion, they must prove that they are qualified to do so. The coroner will verify the witnesses’ credentials and all persons with standing must agree that the person is indeed qualified to provide expert opinions.


When are parties with standing provided inquest materials?

Information related to the inquest (reports, transcripts of interviews, investigative materials, policies, etc.) are provided to parties with standing once they have signed an undertaking. An undertaking is a legal promise not to disclose the information in the coroner’s briefing materials. It is important to the inquest process that materials are only provided to the parties that have been granted standing for review.

Information that will be presented as evidence, entered as an exhibit, or referred to at inquest is provided to counsel, parties with standing, the coroner, and the jury members so that those officially involved in the inquest have the same materials, can refer to them during testimony, and during the jury deliberation.  



How do I address the presiding Coroner?
What is expected of me if I am participating or attending the inquest?
Can I record the proceedings?
What will happen on the first day of inquest and throughout the proceedings?

How do I address the presiding Coroner?

The coroner is addressed as Mister or Madame Coroner.

What is expected of me if I am participating or attending the inquest?

While an inquest is not a criminal court of record, it is nevertheless a court process.  Appropriate behaviour, dress and demeanor will be expected of participants, the media and others attending an inquest.

Cell phones should be silenced, there is no food or drinks in the gallery and all hats need to be removed.  

You can enter and leave the inquest during the proceedings.  Please enter and exit quietly to not disturb witness testimony or the jury who is attentively listening to all the evidence. 

Can I record the proceedings?

Persons are not permitted to use cameras and recording devices in the courtroom. The inquest proceedings are recorded and can be transcribed at a cost to the person or persons making the request. 

Media may make application to the coroner at the beginning of the inquest with regards to using devices and forums such as BlackBerry devices or Twitter.

What will happen on the first day of inquest and throughout the proceedings?

  1. Well before the inquest, the Sheriff’s Office summons a panel of potential jurors to be selected for the inquest.  The potential jurors are asked certain questions to assure the coroner that they are unbiased and suitable for the inquest.  Questions may include:  Who is your employer? Did you know the deceased? Do you know any of the witnesses?
  2. The selected jury will be sworn in.
  3. On the first day of inquest, the coroner starts with opening remarks, including a brief overview of the death.  The coroner will address the jury, explain what their role and responsibilities are, and explain that the inquest is a fact-finding (not fault-finding) proceeding.  No fault or blame may be assigned through the inquest. 
  4. The first witness will be called.  Witnesses make a solemn affirmation or swear an oath.  The party who called the witness will generally lead the questioning.  Then, all other parties will have an opportunity to ask the witness questions, with the coroner and jury going last.  The sequence of who asks questions and in what order is determined by the coroner.
  5. At the conclusion of all witnesses being called and evidence presented, the coroner will then provide a summary of the evidence.
  6. The jury will then be tasked to answer the questions: who, what, when, where and how, and make recommendations, if appropriate. 
  7. Once the jury has completed their deliberations, they return together with the coroner, parties with standing, and interested members of the public and/or media.
  8. The jury verdict and any recommendations will be read by the coroner into the record. 
  9. The verdict and any recommendations are posted to the Department of Justice website for public access.
  10. The chief coroner is then tasked with ensuring that recommendations are implemented.