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Coroners Reports 

The Patient Safety Support Service is committed to disseminating research and information through this website to provide practical and focused resources on patient safety related issues. This section provides an inventory of Coroner’s Reports and Documents which 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.

Please click here for a list of Annual Reports from the Coroner's Office.


For any questions regarding coroner's reports and documents, please contact Saundra Williams, Project Coordinator, Innovation & Adoption at 416-205-1458 or



*Please note that some inquests may be found under multiple categories.


Expand/Collapse Categories : Clinical Practice Guidelines ‎(6)
Expand/Collapse Categories : Communication ‎(24)
Expand/Collapse Categories : Documentation/Health Records/Reporting ‎(10)
Expand/Collapse Categories : Emergency Care ‎(13)
Expand/Collapse Categories : Geriatrics/Long Term Care ‎(9)
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 ‎(29)
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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