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Coroners Reports 

The following is an inventory of individual case reports of coroner's inquests sent to the OHA from the Office of the Chief Coroner. The reports either relate to deaths that occurred in hospitals, or the coroner’s jury, in these inquests, have made recommendations directed at hospitals. Although coroner’s jury recommendations are not legally binding, hospitals may wish to review and consider them. (The Office of the Chief Coroner also publishes annual death review committee reports. Click here for an archive of annual reports).


Please note that the documents on this page do not comprise of the complete inventory of all reports that exist. The Office of the Chief Coroner maintains a more complete archive of its reports. If a specific case report has not been uploaded to the inventory below, please contact the Office of the Chief Coroner directly at 416-314-4000, 1-877-991-9959 or by email at to request a report.


(*Please note that some of the reports below may be found under multiple categories.)


Expand/Collapse Categories : Clinical Practice Guidelines ‎(6)
Expand/Collapse Categories : Communication ‎(29)
Expand/Collapse Categories : Documentation/Health Records/Reporting ‎(10)
Expand/Collapse Categories : Emergency Care ‎(13)
Expand/Collapse Categories : Geriatrics/Long Term Care ‎(10)
Expand/Collapse Categories : Health Human Resources/Staff Education ‎(3)
Expand/Collapse Categories : Homelessness ‎(1)
Expand/Collapse Categories : Homicide ‎(5)
Expand/Collapse Categories : Hospital Policy and Processes ‎(15)
Expand/Collapse Categories : Incident Reporting/Audits ‎(3)
Expand/Collapse Categories : Infection Prevention & Control ‎(1)
Expand/Collapse Categories : Medical Equipment ‎(2)
Expand/Collapse Categories : Medication Incidents ‎(10)
Expand/Collapse Categories : Mental Health and Addictions ‎(21)
Expand/Collapse Categories : Newly Posted ‎(40)
Expand/Collapse Categories : Paediatrics ‎(6)
Expand/Collapse Categories : Patient Involvement ‎(3)
Expand/Collapse Categories : Restraints ‎(6)
Expand/Collapse Categories : Suicide ‎(6)
Expand/Collapse Categories : Transitional Care ‎(13)
Expand/Collapse Categories : Update from the Chief Coroner ‎(4)

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