Québec City, April 17, 2014 – Further to complaints it received concerning the time associated with coroners’ investigations, the Protecteur du citoyen looked into the issue fraught with adverse human and financial consequences for the loved ones of the deceased.
Following this investigation, Ombudsperson Raymonde Saint-Germain made seven recommendations to the Bureau du coroner aimed at speeding up the process of investigation and improving the information given to representatives of the deceased.
Adverse effects in human and financial terms
When a death occurs for which the probable causes cannot be established or which appears to have occurred as a result of negligence or in obscure or violent circumstances, a coroner must conduct an investigation to determine the causes and circumstances of death. Families waiting for the coroner’s conclusions cannot get on with mourning, and, often, grapple with financial insecurity. Indeed, in most cases, private companies and public insurance plans such as those administered by the SAAQ or the CSST require the coroner’s conclusions before beneficiaries are issued compensation.
The impact of lengthy wait times for investigations proves harmful to bereaved families who, to make matters worse, have trouble getting information about how the investigation is progressing and feel abandoned during this trying period of their life.
Findings and causes
The Protecteur du citoyen investigation showed that the average wait time for investigations was 12.2 months in 2012, and 15.1 months for investigations involving an autopsy and an expertise. This is much longer than the 9 months declared on the Bureau du coroner website, and even that is long to wait. In 2012, 2,026 families waited longer than the 9 months declared before obtaining the coroner’s conclusions concerning the death of a loved one. Of these 2,026 families, 799 had to wait more than a year and a half.
These wait times are not caused by coroners alone—they are also due to third parties who contribute to the investigation by providing police reports, medical records, expertise reports and autopsy reports. More specifically, the production of any required autopsy reports by hospital centre or Laboratoire de sciences judiciaires et de médecine légale pathologists alone accounts for 9 months of the average wait time.
As for the wait time attributed to coroners themselves, which represented nearly half (46.3%) of the total average investigation wait time for files closed in 2012, the Protecteur du citoyen investigation found shortcomings in the monitoring and supervision of practices. It noted that the Bureau du coroner has no requirements as to documenting or reporting on how investigations are coming along.
Recommendations
The Protecteur du citoyen believes that the Bureau du coroner must make the reduction of investigation wait times one of its priorities and has therefore made seven recommendations to the Chief Coroner:
- Set a target for reducing investigation wait times;
- Establish an action plan for achieving it;
- Make coroners aware of how important it is for loved ones of the deceased to obtain the conclusions of an investigation as quickly as possible;
- Ensure compliance with obligations concerning the due diligence prescribed in the Act respecting the determination of the causes and circumstances of death regarding transmission of autopsy reports and pre-investigation expertise reports to the coroner;
- Exercise the Chief Coroner’s power to supervise the work of coroners conferred under the Act;
- Inform citizens of real wait times;
- Ensure that families or representatives of the deceased are kept informed of the progress of the investigation.
According to Ombudsperson Raymonde Saint-Germain, "these are realistic solutions that would not require amendment of any act or regulation. They are imperative given the serious consequences of these wait times for bereaved families."
Press relations:
Carole-Anne Huot, 418 646-7143/418 925-7994
carole-anne.huot@protecteurducitoyen.qc.ca
