Tuesday, December 15, 2009

Ontario Acts On Goudge Recommendations

Ontario Acts On Goudge Recommendations


TORONTO, Oct. 23, 2008 /CNW/ - NEWS

Ontario's death investigation system would be stronger, more accountable
and provide for greater oversight and transparency under proposed legislation
introduced by Community Safety and Correctional Services Minister Rick
Bartolucci today. Highlights of the bill include a new oversight council,
complaints committee and a provincial forensic pathology service.
The proposed legislation addresses all the recommended legislative
amendments in the report of the Honourable Justice Stephen Goudge's Inquiry
into Pediatric Forensic Pathology in Ontario. This includes amendments to the
Coroners Act that would establish a framework to strengthen the death
investigation system in Ontario.

The new death investigation oversight council, made up of experts from
the medical, legal and government communities, would oversee the work of the
chief coroner and chief forensic pathologist to ensure the quality of the

The Ontario Forensic Pathology Service recognizes the complex and
important role forensic pathology plays in death investigations. The new
service will centralize forensic pathology under the chief forensic
pathologist, ensuring consistent, high-quality standards for forensic
pathology across the province.



"Commissioner Goudge gave us the roadmap to a stronger more accountable
death investigation system. This legislation takes us a long way down that
road. If passed, it would ensure we have the checks and balances in place to
prevent a similar tragedy in the future," said Community Safety and
Correctional Services Minister Rick Bartolucci

"This legislation would provide us the framework we need to truly
revitalize the system, and to help us build on the work we've already done to
earn back the trust of the people of Ontario," said Ontario's Chief Coroner
Dr. Andrew McCallum (http://webx.newswire.ca/click/?id=2e478d1bd6e0ea3).

"By recognizing the importance of a professional forensic pathology
service, this legislation would help us to take the next step towards
delivering the consistent high quality service the people of Ontario deserve,"
said Ontario's Chief Forensic Pathologist Dr. Michael Pollanen.



Learn more about Ontario's coroners

Read Justice Goudge's report and recommendations

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Proposed new legislation would, if passed, amend the Coroners Act to
improve oversight, accountability and quality assurance within Ontario's death
investigation system. The proposed changes respond to recommendations made by
the Honourable Justice Stephen Goudge following his Inquiry into Pediatric
Forensic Pathology in Ontario.

Key changes under the new legislation would include:


Proposed changes in the legislation would make it easier for the public
to understand how the death investigation system works and would make the
system itself more accessible, transparent and accountable.

A new death investigation oversight council would be created to oversee
the work of the chief coroner and the chief forensic pathologist. This is in
response to Commissioner Goudge's recommendations that an independent
oversight mechanism be established to oversee Ontario's death investigation
system. The council will ensure that the chief coroner and chief forensic
pathologist are held accountable for the quality of death investigations in

Ontario's Lieutenant Governor would appoint members of the oversight
council which would include representatives from the judicial, medical, and
government communities and as such would bring specialized expertise to advise
and oversee the chief coroner and chief forensic pathologist.


A new complaints committee would be established that would report to the
oversight council. The committee would track complaints made about the
handling of a particular death investigation or about the conduct of a coroner
or pathologist during an investigation.

In general terms, complaints concerning the medical roles of coroners and
pathologists would be directed to the College of Physicians and Surgeons,
while complaints related to the non-medical roles of coroners and pathologists
(e.g., providing evidence in criminal proceedings) would be directed to the
chief coroner and chief forensic pathologist respectively.

The committee would ensure the chief coroner and chief forensic
pathologist respond to complaints quickly and thoroughly. If a complainant is
not satisfied with the response provided by the chief coroner or the chief
forensic pathologist, the complaints committee has the authority to review the
complaint. The committee would also review any complaints against the chief
coroner and the chief forensic pathologist.


In his report, Commissioner Goudge identified the vital role that
forensic pathology plays in Ontario's death investigation system. He made
several recommendations directed at improving the oversight of forensic
pathologists, defining their roles and ensuring quality within the system.
These recommendations are addressed in the proposed legislation.

Roles and Responsibilities

The chief forensic pathologist would be established in law as the head of
forensic pathology in the province. This would allow him or her to ensure the
quality and consistency of services being provided by forensic pathologists
across the province. Currently the chief forensic pathologist does not have
this legislated responsibility.

Forensic Pathology Service

A new Forensic Pathology Service would be created reporting to the chief
forensic pathologist. The new service would bring all of the province's
forensic pathology services under one umbrella to ensure consistency,
accountability and oversight. Currently, the province's forensic pathology
services are decentralized and run by regional forensic pathology units and
other hospital facilities where autopsies are performed.

Registry of Pathologists

A registry of pathologists authorized to perform post-mortem examinations
would be created and maintained by the chief forensic pathologist. This would
ensure that all pathologists providing services in Ontario are appropriately
qualified and experienced and have met the strict quality requirement set out
by the chief forensic pathologist.


The chief coroner has a responsibility to protect public safety, and
needs to be given the clear authority to share information for this purpose.
Providing the chief coroner with authority to decide when it is appropriate to
share information to advance public safety will help coroners to protect the
public by preventing similar deaths. In such cases, the coroner would make
every effort to protect privacy by withholding identifying information where

The current legislation allows the coroner to release the results of
death investigations only to family members of the deceased, but does not
allow the coroner to release the results to other groups or to the public.
In some cases, the coroner has a need to share information when not doing
so would put the public at significant risk. For example, if widely used
medical equipment were faulty and caused a death, the public would need to be


The intent of the proposed legislation is to build a stronger death
investigation system based on the principles of professionalism and
accountability. Under such a system, it is the Office of the Chief Coroner who
has the expertise and experience needed to determine if an inquest should be
held. Decisions on inquests can undergo three levels of review within the
Office of the Chief Coroner: local investigating coroner; regional supervising
coroner; and the chief coroner.

If the minister made a decision contrary to the chief coroner's, it would
be inconsistent with the arm's-length relationship between the Office of the
Chief Coroner and government. For this reason, the proposed legislation would
remove the power of the Minister of Community Safety and Correctional Services
to call an inquest.

The chief coroner's decision regarding an inquest could still be the
subject of judicial review, if there was a desire to appeal his or her ruling.
Under this proposed change, by removing any potential for political
intervention, the final decision is based on science.


All deaths of adult inmates in correctional institutions are, and will
continue to be, thoroughly investigated by a coroner who is able to make
recommendations to prevent similar deaths. Currently, a coroner must hold an
inquest into all such deaths. Where the initial investigation determines that
a death in custody was by natural causes, the resulting inquest rarely
provides meaningful recommendations to improve public or inmate safety.
Under the new legislation, a death by natural causes in an adult
correctional facility would no longer be the subject of a mandatory inquest. A
coroner would still be able to call an inquest in such cases if he or she
believes an inquest will lead to improvements in public safety.
This change would allow coroners to focus on those complex cases where an
inquest could result in meaningful recommendations to make Ontario safer.


All Ontarians deserve high-quality services and that includes death
investigations. In his report, Commissioner Goudge recognized that delivering
this service is challenging in some areas of the province. The current
shortage of doctors in northern, First Nations, and remote communities results
in long response times in the event of a death and sometimes coroners are
unable to attend a death scene at all.

As recommended by Commissioner Goudge, the new legislation would provide
for the appointment of individuals other than medical doctors or police
officers to perform coroner's duties. If passed, this amendment will give
coroners the flexibility to meet local needs and improve service to northern
and remote communities. However, the final decision as to whether or not an
inquest is required would continue to rest with the Office of the Chief


It is not always clear to the public what the purpose of a death
investigation is and this can cause confusion while the investigation is
underway. The proposed new legislation would establish in law for the first
time the reasons why a death investigation is undertaken.


The results of an investigation are used to determine whether
recommendations are needed to prevent similar deaths or whether the death
requires the additional public scrutiny of an inquest.

An inquest is a public hearing held under the authority of the Coroners
Act for the purpose of presenting evidence to a jury of five members of the
community in which a person died. After hearing the evidence and other matters
relevant to the circumstances of the death, the jury must answer the above
five questions. They also may make recommendations based on evidence heard
that if implemented, might avoid deaths in similar circumstances.

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