The Law and Mental Disorder Association has made a Submission to the Office of the Chief Coroner regarding these Proposed Legislative Changes.

Learn more about the proposals here on the government’s website.

This is part of the Government’s Summary excerpted

The Ministry of the Solicitor General is proposing the use of mandatory coroner-led annual reviews to examine non-natural deaths in correctional institutions in Ontario and non-natural deaths where the initial injury is sustained at the correctional institution, but the death occurs elsewhere (e.g., in a hospital). The review process would be modelled on the existing Construction Death Review and would replace the current practice of mandatory inquests.

Currently, under subsections 10 (4.3) and (4.5) of the Coroners Act, deaths from non-natural causes that occur while a person is in custody at either a provincial or federal correctional institution in Ontario are subject to mandatory inquest.

LAMDA Opposes this Move to a Review System to Replace Mandatory Custodial Inquests

Review our full Submission here.

For those who may wish to reference LAMDA’s Submission or endorse our position, you may reference the submission, available at this link:

https://drive.google.com/file/d/1vPnJOjifC0aoMTrcEoG34t2UTD-iAGi2/view?usp=sharing

While LAMDA appreciates there are potentially significant benefits to a Coroner’s annual Review System, no administrative review system can or should replace mandatory inquests of non-natural in custody deaths.

DISCUSSION AND ANALYSIS

One of the main drivers of the proposed legislative change is the OCC’s caseload overwhelm, making it challenging to conduct timely important inquests that would examine systemic issues, due to the volume of mandatory inquests that must take priority or in any event require significant resourcing. There is the related concern arising about delays in holding inquests generally, extending the inquest scheduling to 5-7 years from the date of the death. The obvious answer to concerns of this nature is increasing resources for the OCC to decrease delays. The suggestion that inquests cannot commence before other legal processes or investigations are completed, such as criminal trials arising from the circumstances of the death, is often made but does not appear to be statutorily mandated. There are protections against the use of evidence heard at an Inquest in other matters that could well allow for these investigations and hearings to overlap or for the inquest to proceed before other proceedings may follow.

Some other rationale proffered for replacing mandatory inquests with annual reviews relate to inconvenience to professional witnesses and related concerns. The Coroner’s Motto is to “speak for the dead, to protect the living.” Coroner’s Inquest Juries do just this through their Verdicts and Recommendations. They’ve done so for centuries historically and continue to do so in the present day both honourably and with the noblest of purpose. Coroner’s inquests are critically important to public confidence, for transparency and accountability of State actors with the power to incarcerate individuals who die behind locked doors. The Coroner’s Motto is not to “minimize inconvenience to government agencies or experts.” In such life and death matters, administrative efficiency and convenience ought not to be the primary preoccupations of anyone entrusted with investigating, examining, and inquesting custodial deaths. However, preventing future death in similar circumstances may benefit from adding annual systemic Coroner’s reviews to the tools employed in furtherance of this shared societal goal and the OCCs critical role in it. Ideally mandatory inquests would still be held, while annual systemic reviews are added as an additional safeguard and a timely, pro-active measure to prevent such future deaths.

LAMDA does appreciate that similar legislative changes in the context of construction inquests have proven to be successful or in any event have been well-received based on stake-holder experience with them. However, we point out that while most construction deaths are accidental and happen on the premises of private enterprises, death in custody, if not natural, is by suicide, homicide, neglect or overdose and happens out of the sight of the public, in the dark, behind locked doors.

In conclusion, the level of mistrust and frank fear of the current provincial government’s attitude toward populations at greatest risk of being overpoliced, overincarcerated and most vulnerable to harm, physical and mental, within our correctional facilities cannot be overstated and should not be ignored. People are literally terrified of dying in our jails and prisons, and with good reason. The timing of the proposal to eliminate mandatory inquests into their death is disconcerting to these vulnerable individuals. It is exacerbating their sense that they are invisible and dehumanized. Given that, while additional safeguards, including the annual review system, are welcome – doing away with mandatory inquests for correctional deaths other than by natural causes, is unacceptable.