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In all occupational fatalities resulting from an accident, the coroner or similar official will conduct an investigation to determine whether an inquest needs to be held. In some provinces, inquests are mandatory for fatalities in some industries. In Ontario an inquest is required if a worker is killed in a mine or on a construction site. In cases of other occupational fatalities, coroner’s inquest may be held. Nowhere in Canada are inquests mandatory for all occupational fatalities.

In the Province of Ontario, along with British Columbia, Saskatchewan, Quebec, New Brunswick, Prince Edward Island, Northwest Territories and Yukon Territory, operates under a coroner system.  All coroners in Ontario are licensed physicians, usually general practitioners.  They are appointed by the Lieutenant Governor and report to the regional coroner who reports to the chief coroner. The coroner's office obtains investigative information from law enforcement officers.  

Medical examiner systems operate in Alberta, Manitoba, Nova Scotia and Newfoundland.  Unlike the coroner's office, the office of the medical examiner conducts its own investigations

In the coroner system, the responsibility for the initial investigation of reported unusual or sudden death, for deciding whether a public inquiry should be held, and for holding such an inquiry is entrusted to public official know as coroners. However, coroner’s inquest into industrial fatalities appears to have a sorry history.

• Juries are not always composed of workers familiar with the work processes involved
• Policemen unskilled in industrial accident investigation
• Physicians have little training in occupational health and safety
• No consistent, deliberate and forceful attempt is made to ensure implementation of coroner’s jury recommendations in industrial fatalities.

An inquest is a formal hearing into the events surrounding a death.  The purpose is not to place blame, but to obtain a complete understanding of the death based on subpoenaed evidence.  The findings may influence a jury to make recommendations which are designed to prevent similar deaths in the future.  Though not legally binding, these recommendations may have local or province wide impact to workers.

The coroner must determine:

• the identity of the deceased
• when the death occurred
• where the death occurred
• how the death occurred, i.e. the medical cause of death
• by what means the death occurred, i.e. the circumstances surrounding it.

It should also be noted that under the present inquest system a through investigation of the accident and its causes is often not done. In too many cases, the recommendations do not deal with the major, often indirect, causes of the accident. Where recommendations are made, often no follow-up action is taken. Thus hazards which lead to one fatality may not be corrected, leading in turn to others.

In spite of the weaknesses in the present inquest system workers have a great deal to gain by participating in inquests and by pressuring for needed changes in practice and legislation.

Inquests are public. Participating can direct public attention to hazardous conditions and to the need for more stringent health and safety laws and regulations.

The purpose of an inquest is not only to determine the cause of death, but also to look for ways to prevent similar deaths in the future. Evidence is heard from all the witnesses who have information about the deaths. Therefore, it is vital that locals obtain standing at all workplace fatalities so their voice can be heard.

In many provinces the union and worker health and safety committee members do not have standing at inquests; thus’ the expertise tat fellow workers could bring to the inquest is lost. Even in Ontario, where standing should be granted if the coroner finds "that the person is substantially and directly interested in the inquest" (section 41), such standing is often denied.

If locals were to obtain standing at an inquest, they can cross-examine witnesses and present evidence to ensure that all the facts about the accident are brought to the attention of the judge and/or jury.

However, it should be noted that the provisions under health and safety legislations can be utilized only as they apply to the circumstance leading to the workers death.

Evidence may be provided at an inquest which would not be available to the union otherwise.

The findings of an inquest are a matter of public record. Inquest recommendations add weight to the arguments of worker committee members seeking change in the workplace.

Whether workers get standing or not, there is work to be done. It is important that the police conducting the coroner’s investigation understand the accident and its causes.

For information on this and other training programs contact the Workers Health and Safety Centre nearest you, or Visit our web site at: http://www.whsc.on.ca