Bill 115, An Act to amend the Coroners Act, received first reading on October 23, 2008. The Bill reflects the findings and recommendations contained in the report of Justice Stephen Goudge, the commissioner of the Public Inquiry into Pediatric Forensic Pathology. (See for more information.)

In the wake of the finding that Dr. Charles Smith, former director of the Ontario Pediatric Forensic Pathology Unit, had made serious errors in 20 of 45 suspicious deaths over a 10-year period, the Inquiry was charged with conducting “a systemic review and an assessment of the policies, procedures, practices, accountability and oversight mechanisms, quality control measures and institutional arrangements of pediatric forensic pathology in Ontario from 1981 to 2001.” Issued on October 1, 2008 Justice Goudge’s Report included 169 recommendations intended to “restore and enhance public confidence in pediatric forensic pathology in Ontario and its future use in the criminal justice system.”

The Bill also proposed a number of changes to the Coroners Act (the Act) including:

  • Inclusion of definitions for “forensic pathologists” and “pathologists” stipulating that these individuals must be physicians certified by the Royal College of Physicians and Surgeons of Canada (RCPSC) in the appropriate specialties or have received equivalent certification in another jurisdiction;
  • Creation of the Ontario Forensic Pathology Service to oversee the provision of pathologist services;
  • Appointment of a Chief Forensic Pathologist and Deputy Forensic Pathologists with an oversight role for pathologists and pathology services;
  • Creation of a register, to be maintained by the Chief Forensic Pathologist, of pathologists available to provide services under the Act;
  • Creation of a Death Investigation Oversight Council to oversee the Chief Coroner and Chief Forensic Pathologist. The Council would advise and make recommendations on financial resource management, strategic planning, quality assurance, performance measures and accountability mechanisms, appointment and dismissal of senior personnel, compliance with the Act and regulations, and any other matter that is prescribed;
  • Creation of a complaints committee for the Oversight Council. Any person would be able to make a complaint to the committee about a coroner, a pathologist or a person (other than a coroner or pathologist) with powers or duties under section 28 of the Act, which deals with post-mortem examinations;
  • Review of complaints about pathologists by the Chief Forensic Pathologist; review of complaints about coroners by the Chief Coroner; and review of complaints about persons with powers or duties regarding post-mortem examinations by an appropriate person. The complaints committee would also be able to refer the matter to the College of Physicians and Surgeons of Ontario (CPSO) or another person or organization that has power to deal with the complaint if the committee is of the opinion that it would be more appropriate to do so. Persons unhappy with a review could request review of the complaint by the complaints committee;
  • Clarification of the purpose and scope of the coroner’s investigations. The coroner would be required to investigate as he or she deemed necessary in the public interest to determine whether an inquest is required and, if so, to determine the questions to be answered by the inquest, and to collect and analyze information to prevent similar deaths;
  • Rendering inquests mandatory for deaths of persons detained by or in the custody of a peace officer or in a correctional facility, lock-up or other place of secure custody, only if the coroner is of the opinion that death was due to unnatural causes;
  • The repeal of provisions authorizing the Solicitor General to direct a coroner to hold an inquest or appoint a commissioner to hold an inquest, and the transfer of certain powers to call an inquest from the Solicitor General to the Chief Coroner;
  • Permitting the coroner to simply hold an inquest without having to issue a warrant;
  • Requiring that the findings and recommendations of a coroner’s investigation be brought to the attention of the public or a segment of the public if the Chief Coroner reasonably believes this to be necessary in the interests of public safety; and
  • Imposing new reporting and record-keeping obligations where a coroner deems an inquest to be unnecessary.