Coroners service evolving in step with audit

Changes in coroners service

As British Columbia’s chief coroner, I was very pleased with the auditor general’s recent finding the BC Coroners Service is meeting its core mandate – accurately and independently investigating all reported deaths, holding mandatory inquests and reviewing all children’s deaths.

Equally gratifying, the audit identified risks and made eight performance-related recommendations that are consistent with those we’ve identified internally. Plans to address them are underway now.

The audit found we need to increase the public’s understanding of the service’s role and purpose. While our role continues to evolve as the needs of our stakeholders and the public change, we are committed to supplying certain key services expertly and with compassion, and the public can expect this to continue.

The BC Coroners Service is responsible for determining the circumstances of every sudden, unexpected and unnatural death in the province. Each year, our 91 coroners investigate approximately 7,800 deaths. Coroners are on call in every community in the province, at any time of the day, 365 days per year.

In each case, a coroner will attend the scene of the death, examine and take custody of the deceased, liaise with emergency responders and health-care professionals, and provide assistance and information to grieving families. The coroner is legally responsible for determining the identity of the deceased and how, where, when and by what means he or she died.

This responsibility is the same whether the death was a natural event, a suicide, a homicide or an accident. If foul play or unlawful activity is suspected, police will conduct a criminal investigation. While the investigations of the coroner and the police may intersect, they are separate and independent.

Because they live in or near the communities where the deaths occur, B.C. coroners can offer unique insights into the concerns and questions of the deceased’s families, friends and the community.

Beyond investigating to determine the facts of a death, coroners look at whether the death was preventable and make recommendations, where possible, to prevent similar deaths in the future. Coroners may utilize the expertise of pathologists, toxicologists, identification specialists and other experts to assist with their conclusions.

The service also investigates the deaths of all children in B.C. – about 300 a year. Coroners work diligently to ensure families receive the answers they need about their child’s death. Investigations begin immediately upon the report of a death and are concluded as quickly as possible.

Notably, these death investigations are entirely separate from child death reviews. Death investigations by our coroners establish the circumstances of each individual child’s death.

Later, the service’s Child Death Review Unit undertakes reviews to discover and monitor death related trends and determine whether further evaluation is necessary.

By law, this unit can only initiate reviews after all related death investigations are concluded. No family in B.C. waits years to learn the critical facts of their child’s untimely demise.

I am proud the auditor general commented specifically on the dedication and experience of BC Coroners Service staff. We are committed to continuing to conduct thorough, independent investigations into the circumstances of deaths in the province.

Each of us will be working, equally diligently, to use the information we gather to try to prevent future deaths and to improve public safety and quality of life for all British Columbians.

Lisa Lapointe is the chief coroner of the BC Coroners Service.


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