Certain specific situations lead to an investigation and, occasionally, a public coroner’s inquest, for example when a person dies under violent circumstances, when it is impossible to establish the deceased’s identity, or when the cause of death is unknown. In these specific instances, the coroner will shed light on the events by ordering, if need be, a public inquest. The coroner will then make recommendations in a report that is made public.
A coroner, when notified of a death, may conduct an investigation or, more rarely, an inquest if justified by the circumstances.
The coroner is generally notified of a death by a physician or peace officer, but any citizen may notify the coroner of a death. If a death occurs in certain places such as penitentiaries or daycare centres, notification is compulsory.
Investigation
The investigation is an independent process to gather information, during which the coroner must:
- determine the identity of the deceased person;
- determine the date and place of death, the probable causes of death, and the circumstances of death;
- make recommendations directed towards better protection of human life.
During the investigation, the coroner may, in particular, examine and photograph the body, or have it examined or photographed by another person, and order an expert report.
Following the investigation, the coroner must draw up a report, which is a public document filed in the records of the coroners.
A coroner who, during or following an investigation, considers that it would be expedient to hold an inquest , must immediately make a recommendation to that effect to the Chief Coroner (see definitions).
Inquest
An inquest has the same objective as an investigation: to allow the coroner to determine the causes and circumstances of a death. It is not a way to appeal or review the results of an investigation.
The Chief Coroner may order an inquest if, in the opinion of the Chief Coroner:
- it is necessary to hear witnesses under oath at a public inquest;
- the inquest will not impede the progress of any police investigation.
During a public inquest, information and facts are presented to the investigating coroner (see definitions), who may summon as a witness any person who may be in a position to provide useful information. The coroner may also order the person to produce certain objects or documents.
Any person with an interest in the inquest may ask the coroner to be recognized as an interested person.
A public report is drawn up following the inquest and filed in the records of the coroners.
Chief Coroner
Coroner appointed by the government with responsibility for coordinating, distributing and supervising the work of all coroners in Québec.
Investigating coroner
Coroner with legal training designated by the Chief Coroner to conduct inquests.
Any person wishing to obtain information on coroner’s investigations and inquests or who wishes to attend or take part in an inquest.
