Canadian coroner inquests: which provinces publish inquest records

What to take away

Canada has no national coroner database. Each province or territory runs its own system, so the first question is which province held the inquest.
Ontario, British Columbia, Saskatchewan and Alberta post inquest verdicts or reports online. Quebec treats coroner reports as public and releases them on request. Manitoba's Chief Medical Examiner describes its own request route.
An inquest is fact finding, not fault finding. Verdicts and recommendations do not assign legal blame.
Autopsy reports and other annexes are usually harder to get than a verdict, and some offices restrict them.
Always check the posting window. Some sites keep only recent years online.

Inquest records are not coroner reports

The word "inquest" covers a specific, public step. A coroner or medical examiner investigates a death. In some cases a formal inquest follows, where evidence is heard and a jury or judge makes findings and recommendations. Most deaths that a coroner reviews never reach an inquest, so most records in this area are investigation reports instead.

The distinction decides where to look. A verdict with recommendations is a published document in most provinces. A medical examiner's report or an autopsy report is a case file, and access tends to depend on who is asking. If you are researching how death records work in the United States, the US coroner report search covers the equivalent path, and state death record seal rules explain why access varies by jurisdiction.

Ontario

The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year on ontario.ca, with one page per year. It distributes them to the organizations that must act, and asks recipients to respond within six months, saying whether each recommendation was implemented and, if not, why.

Older verdicts and the responses to recommendations are available on request. The office lists an email address (occ.inquiries@ontario.ca) and a phone number (1-877-991-9959) for that. The page also notes that verdicts can be found through Westlaw Canada.

So for an inquest from three or more years ago, a quick web search on ontario.ca will not be enough. Write to the office and give the name of the deceased, the approximate date and the place.

British Columbia

The BC Coroners Service publishes an inquest schedule and archive on gov.bc.ca. Tables list the start date, location, name of the deceased, type of inquest, posted documents and recommendation responses. The archive is organized by year and runs back to 2008.

A jury's verdict is usually posted at the end of the inquest's last day. It contains the findings and recommendations. A "verdict with coroner's comments" replaces it once posted, and keeps the jury's recommendations. Some entries have a "responses" link, though many do not.

The service describes an inquest as a formal court proceeding with a five- to seven-person jury. Inquests are required for deaths in the custody of, or detained by, a peace officer, unless the death was natural and unpreventable or unrelated to custodial care. In other cases the chief coroner decides. If a verdict is not posted, the page tells readers to contact the Coroners Service. For transcripts, it recommends contacting a certified court reporter for an estimate.

Alberta

Alberta uses the term "public fatality inquiry." It is a public legal proceeding before a Court of Justice judge. The Minister of Justice orders an inquiry, with or without a recommendation from the Fatality Review Board, and the public can ask the board to consider one. An inquiry happens only after the police and the Office of the Chief Medical Examiner finish their investigations and related criminal charges, including appeals, are resolved.

After an inquiry the judge releases a report to the public and the Minister. The government posts reports on open.alberta.ca, sorted into categories such as correctional facilities, mental health patients, peace officer-related, child guardianship and work-related. A public tracking system records the deceased's name, the cause and manner of death, the judge's recommendations, and who was asked to respond and what they said.

Alberta also publishes fatality inquiry schedules that list completed inquiries awaiting reports, current inquiries, future inquiries and those waiting on criminal proceedings. If an inquiry you are looking for is not yet posted, the schedule shows where it stands. The reports cannot make findings of legal responsibility.

Saskatchewan

The Saskatchewan Coroners Service lists three kinds of inquest records online: inquest schedules by calendar year, jury findings and recommendations (listed alphabetically by the last name of the deceased), and responses to recommendations.

The service describes an inquest as a public hearing before six jury members, "fact finding, not fault finding." Inquests are mandatory when someone dies in custody, unless the death was natural and not preventable. The chief coroner can also call discretionary inquests. The jury decides who died and how, when, where and by what means, and may recommend ways to prevent similar deaths.

Post-mortem examination reports and coroner's reports are requested through a separate form linked from the service's page. The page does not describe fees or eligibility, so check the form.

Manitoba

Manitoba's Chief Medical Examiner decides whether an inquest is needed and may call one if the public would benefit. Inquests are usually held in Provincial Court before a provincial judge, with a Crown attorney representing the public interest. The judge may make recommendations, and the page states that the process is not a means to determine culpability.

The office's page does not say where finished inquest reports are published, so contact the Chief Medical Examiner's office to ask. For medical examiner and autopsy reports, adult next of kin can request both in writing. Attending physicians and hospital medical reports departments can also request them. Other interested parties, such as a life insurer or a legal representative, can receive them on written request and payment of the prescribed fee under The Fatality Inquiries Act. The page gives no amount.

Quebec

Quebec's Bureau du coroner takes a different approach. Coroner reports are public, and anyone can ask for one. The request can be made through an online form, by phone to the customer service line (1 888 CORONER, or 1 888 267-6637), by emailing clientele.coroner@coroner.gouv.qc.ca, or by sending a printable form by mail or fax. Journalists send requests to the communications team.

For a death before 3 March 1986, the request goes to the regional service centre of the Archives nationales du Québec instead. The request page does not list fees or processing times.

Reports published in the bureau's recommendations section are often anonymized, with the deceased's name removed. The original version, with the name, is obtained by making a report request. Annexes to a report, such as the autopsy report, toxicology report, medical file and police officer's report, are confidential. The chief coroner can authorize access for someone who shows the documents are needed to have their rights recognized, or for a public body that shows they serve the public interest. The police report also needs permission from the Minister of Public Security. The bureau lists a fee of CAD 34 per annex when a request is accepted.

Reading a verdict

A verdict generally gives who died, and when, where and how they died, followed by recommendations addressed to named bodies. The jury or judge does not find civil or criminal liability. Read the recommendations for what agencies were told to change, then look for a response where the province posts them. For plain-language definitions of terms such as manner and cause, cause of death guides explains how those lines are worded.

When you publish or repeat what a verdict says, stick to its wording. The note on libel and privacy law in celebrity death corrections is a useful reminder of the care needed with names and causes.

A request checklist

Identify the provincewhere the death occurred. Jurisdiction follows the place, not where the person lived.
Check the online list first(Ontario current and prior year, BC archive, Saskatchewan alphabetical list, Alberta report categories).
Write to the officefor older or unposted records, with the full name, date of death and place.
Ask for the verdict or report, not the full file, unless you are entitled to more.
Note the response recordwhere the province keeps one, so you can see what changed after the recommendations.

Common questions

Can anyone read an inquest verdict?

Where a province posts verdicts or reports, yes. Quebec says its coroner reports are public. Manitoba restricts medical examiner and autopsy reports to the people it lists.

Do verdicts name the deceased?

Usually. Quebec's published recommendations section is often anonymized, with the full report available on request.

How far back does Ontario's website go?

The current year and the previous year.