Death Investigations and Panels

All deaths that are unnatural, unexpected, unexplained or unattended must be reported to a coroner. Upon receiving a report of a death, the coroner begins an investigation, which proceeds in one of three ways: Natural Death, Coroner's Investigation or Coroner's Inquest.

Natural Death

If, after reviewing the circumstances of death and speaking with the personal physician, the coroner determines that the death was due to a natural causes, the coroner will contact the personal physician of the deceased to obtain information on medical history. If it is confirmed that the death is natural, the responsibility for completing the medical death certificate remains with the physician, and no further investigation from the Coroners Service is required. See Section 15 of the Coroners Act for more information.

Coroner's Investigation

An investigation is conducted and a coroner’s report is written. When a death is reported to the coroner, he/she has the authority to collect information, conduct interviews, inspect and seize documents and secure the scene. Upon conclusion, the facts as determined by the investigation are released in a report. It sets out the coroner’s findings, including a cause of death and whenever possible, recommendations to prevent future deaths. For a copy of the coroner's report contact the regional coroner office in your area. Please note, an investigation may be reopened on the grounds that new evidence has arisen or has been discovered. An application to reopen an investigation is made by writing a letter to the Chief Coroner outlining the new evidence.

Coroner's Inquests

Inquests are formal court proceedings, with a five-person jury, held to publicly review the circumstances of a death. The jury hears evidence from witnesses under subpoena in order to determine the facts of the death. The presiding coroner is responsible to ensure the jury maintains the goal of fact finding, not fault finding. Once an inquest is held, a Verdict at Inquest is written.

Some inquests are mandatory under Section 18 of the Coroners Act (for example, if the deceased was in the care or control or a police officer or in a police lock-up at the time of their death) . An inquest can also be held if the chief coroner determines that it would be beneficial in: addressing community concern about a death, assisting in finding information about the deceased or circumstances around a death and or drawing attention to a cause of death if such awareness can prevent future deaths.

Upon conclusion, a written report, the Verdict at Inquest is prepared. It includes the classification of the death and whenever possible recommendations of the jury on how to prevent a similar death. The Verdict at Inquest for some inquests is posted (along with any upcoming scheduled inquests) on the Inquest Schedule and Outcomes page. For a copy of the Verdict at Inquest that is not posted, please contact the regional coroner's office in your area.

Child Death Review Unit

The Child Death Review Unit (CDRU) of the BC Coroners Service reviews the deaths of all children age 18 and under in B.C. The intent of these reviews is to better understand how and why children die, and to use those findings to prevent other deaths and improve the health, safety and well-being of all children in British Columbia (View Reports from the Child Death Review Unit).

Death Review Panels

Death review panels are undertaken to fully examine the circumstances in deaths, in order to develop recommendations to reduce the likelihood of similar deaths in the future.

Medical Assistance in Dying

The Coroners Act requires physicians and nurse practitioners to report the death of anyone who has received medical assistance in dying.