Coroners play an important role in public safety by investigating the circumstances of unexpected, unnatural, or unexplained deaths.  These specialized medical doctors endeavour to “ensure that no death will be overlooked, concealed or ignored” and to make recommendations to prevent similar deaths in the future.

Midwives may be contacted by a local coroner in the highly rare circumstances of a client’s death (e.g., motor vehicle accident). In the course of their investigation, the coroner may speak with family and friends, order an autopsy, or request health-care records. Midwives should cooperate with coroner investigations and can access expert advice through AOM On Call if contacted by a coroner.

All deaths during pregnancy and six weeks postpartum are reviewed by the Maternal and Perinatal Death Review Committee of the Office of the Chief Coroner; the committee also reviews stillbirths and neonatal deaths where concerns are raised about the care received. The Committee releases a report annually making recommendations to prevent similar deaths in the future. The AOM’s Quality, Insurance and Risk Management Committee carefully reviews this annual report for themes of particular relevance to midwives.

The local coroner can also make a recommendation to the chief coroner as to whether or not an inquest should be held “for the purpose of informing the public about the circumstances of a death.” An inquest is generally a public hearing, presided over by a coroner, where a jury will make findings and recommendations, but not a finding of legal responsibility. The objective of these non-binding recommendations is to prevent similar deaths through their implementation.  

For more information about the coroner, refer to the Ministry of Community and Social Services website.