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Joel Cahn (100)

Forensic Coroners Act Guest Speaker

Forensic Science
Course Code
Joel Cahn

of 3
Forensics- October 26 th
/ Coroners System
- Derived from the English law, dates back to the 11th century
- The most important function has always been to inquire into unexpected deaths
- The coroner is responsible for establishing facts of a particular death:
oName of deceased
oPlace of death
oTime of death
oCause of death
oManner of death
- Coroner System also serves a preventative function
oIncrease safety through inquests investigation
oPrevention of deaths from similar circumstances
In Ontario:
- Coroner based system is under direction of chief coroner
- All coroners are medical doctors with additional training in death investigation
- Most coroner systems in the rest of the world have non-medical coroners
- Investigates approx. 18.000 deaths a year, one quarter of provincial total
- House the forensic pathology service:
- Medio-legal autopsies, performed by forensic pathologists
oStorage of bodies
oSign off on cremation certificates
oOut of province shipments
oDonated and unclaimed bodies
Administers coroners act
Coroners Act
- law that sets out in the jurisdiction, role and powers of Coroners
- states that its responsibility of everyone to notify coroner in cases of”
onon- natural death
osudden and unexpected natural deaths
odeath in other specified circumstances
ocoroner has exclusive authority over body
- public hearing under authority of coroners act
- present evidence to a jury of five members of community of deceased
- answer the 5 questions of death investigation
- Most accurate version of facts
- Make recommendations to avoid future deaths
omandatory inquests:
odeaths in custody, or in psychiatric facility
oaccidental deaths on construction sites
ocertain death of children
-Discretionary inquests carried out when in opinion of coroner:
Jury may be able to assist with answering 5 questions
Desirable that public fully informed of circumstances
When likely that jury may makes recommendations to avoid similar deaths
-an inquest is not:
a trial (no assigning og guilt or responsibility
a discovery process or tool
legal binding (no one is legally required to respond to recommendations)
Agents of Change
- preventative function of inquests very important
encourages changes that result in increased safety:
changes in legislation (graduated licensing, labour laws)
policy (how police and courts administer justice)
procedures (protecting children, safer medical practices)
product development (safety equipment in vehicles)
The Gouge Inquiry
- inquiry into Pediatric Forensic Pathology in Ontario
- Rising concerns over how criminally suspicious deaths involving children handled by the
- By mid 2000’s numerous errors confirmed
oBut most cases reinvestigated were those in which Dr. C Smith has provided his
expert opinion
- Large number of wrongful convictions
oProvince called for inquiry in forensic pathology
oSuggestions improve system
- Prevent errors from occurring
- Several problems unearthed:
oLack of qualifications of practitioners of pediatric forensic pathology
ono formal certification
- lack of training on forensic aspects
- lack of knowledge of legal system and role within it
- lack of oversight over determinations
ono checks and balances, redundancies safeguards
Amendment Act
- Passed in 2009 in response to recommendations by the inquiry
oCreation of an oversight council
oImproved handling of complaints
oCreation of Ontario Forensic Pathology Service
oRegistry of pathologists authorized to conduct autopsies
oImproved death investigations for the First Nations and northern communities
Ontario Forensic Pathology Service
- created in July 2009
- registered Forensic Pathologists performed coroner ordered autopsies under leadership of
Chief forensic pathologists
- pathologists are specialized medical doctors
o5 years of additional training after medical school in pathology
Forensic Pathologists
- Have post- grad training in forensic pathology
- Provide expert witness testimony in several different courts
- Training in application of medicine to legal issues
- Through the registry, pathologists matched to autopsies consistent with expertise
The Coroner and the Forensic Pathologists
- work together in death investigation
- coroner has authority of the body and the overall death investigation
- listens to opinions of others, but has the final decision with respect to conducting
- forensic pathologists responsible for conducting the autopsy, other necessary
examinations and the resultant finding