Discretionary Inquests

With the changes made to Regulation 180 of the Coroners Act, the role of the Death Investigation Oversight Council (DIOC) was expanded to allow it to provide advice and make recommendations to the Chief Coroner with respect to whether a discretionary inquest should be called.

While mandatory inquests are required by law for certain types of deaths, discretionary inquests are called by the Chief Coroner when it is believed that systemic issues, when brought to light and examined in an inquest, can advance public safety.

The legislative authority for determining whether a discretionary inquest should be called still rests with the Chief Coroner.  DIOC will, however, add a public voice to the discretionary inquest process, enabling the Chief Coroner to consider a broader range of perspectives in his deliberations.

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General Questions Regarding Discretionary Inquest Reviews

Q: What is an inquest?

An inquest is a public hearing designed to focus public attention on the circumstances of a death through an objective examination of facts.  At the conclusion of an inquest, the five-person jury often makes recommendations that may prevent deaths in similar circumstances.

Q: What is NOT an inquest?

An inquest is NOT an adversarial process, and is not intended to assign blame or to express any conclusion of law (i.e. it is not a trial or a process for discovery).  It is also not a royal commission, a campaign or crusade directed by personal or philosophical agendas.

Q: What is the difference between a mandatory inquest and a discretionary inquest?

Mandatory inquests are conducted for certain types of death, as specified by the Coroners Act.

All other inquests are considered discretionary and may be conducted in accordance with section 20 of the Coroners Act.

Q: Can I request a discretionary inquest and how do I do so?

The spouse, parent, child, brother, sister or personal representative of the deceased person may request that an inquest be held.

The request must be made to the coroner, in writing, and the coroner shall give the person requesting the inquest an opportunity to state his or her reasons, either personally, by the person’s agent or in writing. 

The coroner will present this request to the Regional Supervising Coroner (RSC) management team, who will determine whether an inquest should be conducted.

Q: What recourse do I have if my request for a discretionary inquest is denied?

If the RSC decides to not call an inquest, you may request the Chief Coroner to review the decision by stating your reasons personally, through an agent or in writing.

The request for a review by the Chief Coroner should be made within twenty (20) days of receiving the RSC’s decision to not call an inquest.

Your request and any supporting documents can be sent to the Chief Coroner at:

25 Morton Shulman Avenue, 2nd Floor
Toronto, ON
M3M 0B1

Q: How does DIOC become involved in the discretionary inquest process?

Upon receipt of a request for review (under subsection 26 (2) of the Coroners Act), the Chief Coroner will provide the coroner’s investigation file to DIOC for its Inquest Committee to review.  The investigation file should include the request for a review and supporting documents that can assist the Committee in making an informed recommendation.

In its review of the request and file, DIOC’s Inquest Committee will consider the public’s interest and will also review the RSC’s decision.  The Committee will recommend to the Chief Coroner, in writing, whether a discretionary inquest should be called.

The Chief Coroner will consider DIOC’s recommendation and his findings based on his own parallel review, and will make a decision on whether a discretionary inquest should be called.

Q: What happens if I have additional information that I would like to be considered in in my subsection 26 (2) request for review?

If you have additional information that supports your reasons for a discretionary inquest, you can provide the information to the Chief Coroner. The Chief Coroner will ensure DIOC receives any additional information provided.

Please note that any delay in receiving additional information may result in a delay in completing the review. 

Q: On average, how long does a review of a subsection 26 (2) request take?

Timelines for completing a review and making a recommendation to the Chief Coroner will depend on a number of factors, including the complexity of the case.

DIOC’s Inquest Committee will be communicating with the Chief Coroner to determine what a reasonable timeframe would be for each individual case.

Q: Will I receive a copy of DIOC’s advice to the Chief Coroner?

DIOC’s recommendation, including its rationale, will be attached to the Chief Coroner’s decision to the requestor.

Q: How does my request under subsection 26 (2) affect DIOC’s complaints process?

Pursuant to subsection 8.4 (3), DIOC’s Complaints Committee will NOT review complaints about a coroner’s decision:

  • to hold or not hold an inquest;
  • respecting the scheduling of an inquest; and/or
  • relating to the conduct of an inquest, including any decisions made while presiding at an inquest.

The final decision on whether to hold a discretionary inquest rests with the Chief Coroner.

Q: I have additional questions re: discretionary inquest reviews, who do I contact?

If you have questions re: the discretionary inquest process in general or have questions re: your specific request, please contact the Office of the Chief Coroner by:

 If you questions are re: DIOC’s role in the review of subsection 26 (2) cases or DIOC’s review process for such cases, please click on the “Contact Us” tab for our contact information.