Resolving Unexpected Death and the Role of the Coroner’s Office


A sudden and unexpected death of a loved one is undoubtedly one of the most painful and distressful events of a person’s life. The surviving family may have a desperate need for answers as to how, when and why their loved ones died. Who can they turn to for answers?

In British Columbia, the office of the Coroners Service is responsible for the investigation of all unnatural, sudden and unexpected, unexplained or unattended deaths.  Once the death is reported to the Coroners Service, the Coroner begins a preliminary investigation. The preliminary investigation may lead to one of the following:

1.      Natural death. If the Coroner’s preliminary investigation reveals the death is a natural event, the Coroner will consult the deceased’s family doctor to ensure the nature of the death is consistent with the deceased’s medical history. Once confirmed that the death is natural, the family doctor completes the Medical Certificate of Death.

2.      Further Coroner’s investigation. The Coroner has the authority to conduct a full investigation, including collecting information, conducting interviews, inspecting and seizing documents, and ordering an autopsy. The result of Coroner’s investigation is released in a report, which may not be automatically sent to the family. However, the report is a public document, and is available by request from the Regional Coroner’s office.  

3.      Coroner’s Inquest. The Coroner may determine that it would be beneficial to hold a Coroner’s Inquest, which is a formal court proceeding held to publicly review the circumstances of a death. Normally, an inquest is held to assist in finding information about the deceased or circumstances around a death, to address community concern about a death or to draw attention to a cause of death if such awareness can prevent future deaths. Upon the conclusion of the Inquest, a written report is prepared.

Please note that the Coroner does not assign fault or liability, but conducts a fact-finding investigation into deaths that are unnatural, unexpected, unexplained or unattended. One of the most important purposes of a Coroner’s investigation is to identify risk factors to prevent future deaths.  As such, a written Coroner’s report includes, whenever possible, recommendations to prevent further deaths.

It was recently reported that BC has the lowest autopsy rate in Canada, raising concern amongst some experts that too many deaths in the province, and even possible homicides, are inadequately investigated. The funding cutbacks to the Coroners Service may have contributed to the concern. The Coroner obviously has some discretion in determining whether a full investigation is required for a particular case. With funding pressures, that discretion may be exercised more conservatively. As such, it is essential that family members be proactive and ensure that if a full investigation is warranted that their concerns be brought to the attention of the Coroner’s office.