Our system of death investigation allows for the appropriate review of medical records and care provision. This review occurs through the process of investigating the death to establish an answer to the five questions (who died, where, when, how and by what means), determining the requirement for an inquest and analyzing all the data generated by the investigation.

Additional examination of deaths where the presiding or supervising coroner believes there are systemic issues allows examination by an interdisciplinary expert group to elucidate opportunities for improvement that can be communicated to agencies in a position to assist with implementation and education. Recommendations issued by the PSRC are non-blaming and targeted to actions that are deemed likely to reduce the likelihood of recurrence of similar deaths. Recommendations issued by the PSRC are not tracked; however, feedback from agencies indicates that they are well-received, and many have been implemented.

The mandate of our office as directed by the Coroners Act is one that involves all non-natural deaths and some natural deaths. The healthcare system, through its various investigative and oversight agencies, can help provide other analytical pathways for some of the natural deaths that are currently managed by the OCC. This coordinated and more effective/efficient system of patient safety is one that our office is working toward further establishing.