Module 3 The Role of the Coroner
When to Call a Coroner
Every person has a legal responsibility to report deaths to a Coroner that fall under Sections 7 to 10 of The Coroners Act, 1999. Sections 7 to 10 of the Act states:
7(1) Every person shall immediately notify a coroner or a peace officer of any death that the persons knows or has reason to believe: (a) Occurred as a result of an accident or violence or was self-inflicted; (b) Occurred from a cause other than disease or sickness; (c) Occurred as a result of negligence, misconduct or malpractice on the part of others; (d) Occurred suddenly and unexpectedly when the deceased appeared to be in good health; ( Deaths that occurred suddenly and unexpectedly when the deceased appeared to be in good health typically include, but are not limited to, deaths where the deceased had no pre-existing medical history) (e) Occurred in Saskatchewan under circumstances in which the body is not available because: (i) The body or part of the body has been destroyed; (ii) The body is in a place from which it cannot be recovered; or (iii) The body cannot be located; (f) Was a stillbirth that occurred without the presence of a duly qualified medical practitioner; (g) Occurred as a direct or immediate consequence of the deceased being engaged in employment, an occupation or a business; or (h) Occurred under circumstances that require investigation. (2) Every peace officer who is notified of a death pursuant to subsection (1) shall immediately notify a coroner of the death. 8(1) Where an inmate of a jail, military guardroom, remand center, penitentiary, lock-up or place where the person is held under a warrant of a judge or a correctional facility as defined in The Correctional Services Act, 2012 dies, the person in charge of that place shall immediately notify a coroner of the death. (2) Where a person dies while in a custody facility as defined in The Youth Justice Administration Act, the person in charge of that facility shall immediately notify a coroner of the death. (3) Where a minor dies while a resident of a foster home, group home or place of safety within the meaning of The Child and Family Services Act, the person in charge of that place shall immediately notify a coroner of the death. (4) Where an involuntary patient admitted pursuant to section 23 or 24, or detained pursuant to section 24.1, of The Mental Health Services Act to an inpatient facility within the meaning of that Act dies, the person in charge of that facility shall immediately notify a coroner of the death. (5) The duty mentioned in this section applies whether or not: (a) the person died on the premises or in actual custody; or (b) the person was an inmate, resident or patient at the time of death if the death was caused at that place. (6) Where a person dies while in a hospital to which the person was transferred from a place mentioned in this section, the person in charge of the hospital shall immediately notify the coroner of the death. 9 Where a person dies as a result of an act or omission of a peace officer in the course of duty or while detained by or in the custody of a peace officer, the peace officer shall immediately notify a coroner of the death. 10 Where a minor dies while under the care, custody or supervision of the Minister of Community Resources and Employment, officers or employees of the Department of Community Resources and Employment or its designates or an agency that has entered into an agreement with the Minister of Community Resources and Employment pursuant to section 61 of The Child and Family Services Act, an officer or employee of the Department of Community Resources and Employment, its designate or the agency who has knowledge of the death shall immediately notify a coroner of the death (pages 6-8).
Once a coroner has been called, there is an OBLIGATION TO SECURE THE SCENE AND BODY. The area around the deceased should be protected and secured leaving all items and objects in their place as they were at the time that the individual died. If during their investigation, the coroner determines that the police should be notified, the coroner will do so. The deceased should not be moved until authorized by the coroner. Medical equipment, including lines, tubes, solutions and medical devices are not to be removed without the permission of the coroner. If the coroner cannot attend the scene, it is reasonable to ask the coroner what medical equipment/devices can be removed. Staff or other witnesses to the death who can provide information related to the circumstances of the death and/or the medical/social history of the individual should make themselves available to the coroner (or police as the case may be) for questioning (Saskatchewan Coroners Service, n.d.).
There will be times when a death occurs in a home, hospital, or a care home from natural causes (disease or sickness) but no planning has been done. While the death may appear to be sudden, it is not unexpected particularly given the person’s medical history, recent illness, age, or a combination of these. Like palliative care, these deaths do not fall under The Coroners Act, 1999 and as such, they are not reportable to the coroner or police. The deceased’s family physician or the physician or nurse practitioner who was in attendance at the last illness has an ethical obligation to attend and/or complete the Medical Cause of Death (Saskatchewan Coroners Service, n.d.).
Deaths that occur within 24 hours of admission to hospital, and meet the criteria of death due to disease or sickness are considered natural even though they were sudden. There is no provision in the act that requires reporting the death to a coroner.
There are times that deaths occur in hospital for which there is probable cause that points to a natural death but there is clinical interest on behalf of medical staff or families for an autopsy to be completed. It is not the responsibility of the coroner to become involved solely for the purpose of authorizing a postmortem examination. If the coroner determines the death is reportable under The Coroners Act, they must decide whether or not a post mortem examination is required for the purposes of their investigation (Saskatchewan Coroners Service, n.d.).
In general, the time interval between an injury/poisoning event and death is not relevant in regard to the classification if the death resulted from the effects or complications of the injury/poisoning and there is no clear supervening cause. For example, if a person dies 10 years after being in a motor vehicle accident, with death resulting from pneumonia as a result of quadriplegia caused by the accident, the manner of death would be classified as an accident. The “but-for” principle is commonly applicable to this situation. “But-for the injury, would the person have died when he/she did?” A coroner must be involved in these types of deaths (Hanzlick et al., 2002).