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Coroner Reports and Documents

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 occ.inquiries@ontario.ca to request a report.

Individual Case Reports

	Edit	Title
Category : Clinical Practice Guidelines ‎(6)
		Johanne Desrocher Inquest - Clinical Practice Guidelines
		Lana Dale Lewis Inquest - Clinical Practice Guidelines
		Memo - Management of an Unclaimed Body
		MPDRC Report - Neonatal Death - Clinical Practice Guidelines
		PSRC Report - Death Caused by Metastatic Breast Carcinoma - Clinical Practice Guidelines
		Wayne Howard Inquest - Clinical Practice Guidelines
Category : Communication ‎(29)
		2010 Education Catalogue final
		2012-13652 (PSRC-2015-02)
		2013-9416 (PSRC-2015-04)
		Angelina Peluso Inquest - Communication
		Bolger Inquest
		Bryan Dukic Inquest - Communication
		Christopher Kelly Robertson Inquest - Communication
		Christopher Magee Inquest - Communication
		Clarification of Recommendation from PSRC - Communication
		Derek McCracken Inquest - Communication
		Gary Orven Spurn Inquest - Communication
		James O'Brien Inquest - Communication
		Jeffrey Thomas Elliott Inquest - Communication
		Johanne Desrocher Inquest - Communication
		John Allen Marskell Inquest
		Lumgair Cutler Wibberly - Communication
		Marie Tanner Inquest - Communication
		Mark Charles Barber Inquest
		Mark Wilfred Orser Inquest - Communication
		MPDRC - 2013-5114
		Negus Tefari Topey Inquest - Communication
		PSRC - 2013-15583 (PSRC-2015-03)
		PSRC - Hemodialysis - Communication
		PSRC - Post-surgical T-tube Complication - Communication
		PSRC - Subarrachnoid Hemorrhage - Communication
		Robert Smilanich Inquest - Communication
		Tamara Nakic Appendix 1 - Communication
		Tamara Nakic Appendix 2 - Communication
		Tamara Nakic Inquest - Communication
Category : Documentation/Health Records/Reporting ‎(9)
		Eoin Stalker Inquest - Documentation,Health Records,Reporting
		Helena Vanderkolff Inquest - Documentation,Health Records,Reporting
		Helena Vanderkolff Verdict - Documentation,Health Records,Reporting
		Johanne Desrocher Inquest - Documentation,Health Records,Reporting
		Lumgair Cutler Wibberly - Documentation - Records - Reporting
		Mark Alexader Wiens Inquest - Documentation, Health Records, Reporting
		Negus Tefari Topey Inquest - Documentation,Health Records,Reporting
		Tamara Nakic Appendix 1 - Documentation,Health Records,Reporting
		Tamara Nakic Appendix 2 - Documentation,Health Records,Reporting
Category : Emergency Care ‎(13)
		Bryan Dukic Inquest - Emergency Care
		Christopher Magee Inquest - Emergency Care
		Johanne Desrocher Inquest - Emergency Care
		Methusan Vijayaratnam Inquest - Emergency Care
		MPDRC Report - Peripartum Cardiomyopathy - Emergency Care
		Oster, Bell, McKay, D Evans and J Evans Inquest - Emergency Care
		Peter Lamonday Inquest - Emergency Care
		PSRC - Blockage of Hickman Line for Flolan Pump - Emergency Care
		PSRC - Medication Incident During Therapy for Sickle Cell Crisis - Emergency Care
		PSRC - Pneumonia Order Sets - Emergency Care
		PSRC Report - Death Caused by Narcotic Toxicity - Emergency Care
		Reilly Kennedy Anzovino Inquest - Emergency Care
		Szamko Inquest - Emergency Care
Category : Geriatrics/Long Term Care ‎(10)
		2013-10035 (GLTCRC-2016-05)
		ALC Placement Recommendations
		Death at Home for the Aged - Geriatrics-Long Term Care
		El-Roubi and Lopez Inquest - Geriatrics,Long Term Care
		GLTCRC - Death of 92 year old woman entrapped between bed frame and rail - Geriatrics-Long Term Care
		GLTCRC- Death of 81 year old man due to hospital-acquired pneumonia - Geriatric-Long Term Care
		Helena Vanderkolff Inquest - Geriatrics,Long Term Care
		Helena Vanderkolff Verdict - Geriatrics,Long Term Care
		PSRC - Death Due to Hydromorphone Medication Error - Geriatric-Long Term Care
		PSRC - Death of Elderly Woman - Medication Error - Geriatric-Long-Term Care
Category : Health Human Resources/Staff Education ‎(3)
		Eoin Stalker Inquest - Health Human Resources,Staff Education
		Lana Dale Lewis Inquest - Health Human Resources,Staff Education
		Lumgair Cutler Wibberly - Health Human Resources,Staff Education
Category : Homelessness ‎(1)
		Negus Tefari Topey Inquest - Homelessness
Category : Homicide ‎(5)
		Dupont-Daniel Inquest - Implementation of the Jury Recommendations - One Year Report --Homicide
		Dupont-Daniel Inquest - Implementing the Recommendations --Homicide
		Dupont-Daniel Inquest - Jury Recommendations - Dupont-Daniel Inquest December 2007 --Homicide
		DVDRC Report - Death Due to Sharp Force Injuries - Homicide
		Michael Douglas Inquest -Homicide
Category : Hospital Policy and Processes ‎(15)
		Christopher Magee Inquest - Hospital Policy and Processes
		Clarification of Recommendation from PSRC - Hospital Policy and Processes
		Death at Home for the Aged - Hospital Policy and Processes
		Denise Blais Inquest - Hospital Policy and Processes
		Derek McCracken Inquest - Hospital Policy and Processes
		Eoin Stalker Inquest - Hospital Policy and Processes
		Johanne Desrocher Inquest - Hospital Policy and Processes
		Lumgair Cutler Wibberly - Hospital Policy and Processes
		Marie Tanner Inquest - Hospital Policy and Processes
		Mark Alexader Wiens Inquest - Hospital Policy and Processes
		MPDRC - Death Due to Amniotic Fluid Embolus - Hospital Policy and Processes
		Paramjeet Singh Padda Inquest - Hospital Policy and Processes
		PSRC - Blockage of Hickman Line for Flolan Pump - Hospital Policy and Processes
		PSRC - Hemodialysis - Hospital Policy and Processes
		PSRC - Medication Incident During Therapy for Sickle Cell Crisis - Hospital Policy and Processes
Category : Incident Reporting/Audits ‎(3)
		Eoin Stalker Inquest - Incident Reporting,Audits
		Johanne Desrocher Inquest - Incident Reporting,Audits
		Lumgair Cutler Wibberly - Incident Reporting,Audits
Category : Infection Prevention & Control ‎(1)
		Recommendations for Hospitals to prevent Clostridium Difficile Outbreaks
Category : Medical Equipment ‎(2)
		PDRC - Death Due to Haemorrhagic Shock - Medical Equipment
		Robert Smilanich Inquest - Medical Equipment
Category : Medication Incidents ‎(10)
		Johnathon David Weeks Inquest - Medication Incidents
		Marie Tanner Inquest - Medication Incidents
		PSRC - Death Due to Hydromorphone Medication Error - Medication Incidents
		PSRC - Death of Elderly Woman - Medication Error - Medication Incidents
		PSRC - Medication Incident During Therapy for Sickle Cell Crisis - Medication Incidents
		PSRC Report - Death Caused by Metastatic Breast Carcinoma - Medication Incidents
		PSRC Report - Death Caused by Narcotic Toxicity - Medication Incidents
		Sara Carlin Inquest - Medication Incidents
		Wade Lamont Hatt Inquest
		William Thomas Hart Inquest - Medication Incidents
Category : Mental Health and Addictions ‎(21)
		Andre Serge Lemieux Inquest - Mental Health and Addictions
		Denise Blais Inquest - Mental Health and Addictions
		DVDRC Report - Death Due to Sharp Force Injuries - Mental Health
		Edward McNeil Inquest
		El-Roubi and Lopez Inquest - Mental Health and Addictions
		Gary Orven Spurn Inquest - Mental Health and Addictions
		James O'Brien Inquest - Mental Health and Addictions
		Jeffrey Marreel Inquest - Mental Health and Addictions
		John Carl Bolger Inquest
		Johnathon David Weeks Inquest - Mental Health and Addictions
		Kerry Nicole Cuddy Inquest - Mental Health and Addictions
		Mark Alexader Wiens Inquest - Mental Health and Addictions
		Mark Wilfred Orser Inquest - Mental Health and Addictions
		Michael Douglas Inquest
		Oster,Bell,McKay,Evans and Evans Inquest - Mental Health and Addictions
		Otto Vass Inquest
		Peter Lamonday Inquest - Mental Health and Addictions
		Robert Walker Inquest
		Sara Carlin Inquest - Mental Health and Addictions
		Stephane Michaud Inquest - Mental and Health Addictions
		William Thomas Hart Inquest - Mental Health and Addictions
Category : Newly Posted ‎(40)
		Christopher Skinner Inquest
		DVDRC-2015-06 - Death of a 88-year old male due to suicide-homicide
		Ernie Schilcher Inquest
		Evan Thomas Jones Inquest
		George Kononow Inquest
		GLTCRC - Death due to complications of hypothyroidism
		GLTCRC - Death due to Pneumonia secondary to fall-related hip fracture
		GLTCRC - Death Due to Pseudomembraneous Colitis
		GLTCRC - Death Due to Ventilator Disconnection
		GLTCRC - Death of 87 year old woman due to fall from elevated bed
		GLTCRC - Death of 88 year old woman due to pulmonary thromboembolism and brochopneumonia
		GLTCRC - Deaths due to head injury after same-level fall
		GLTCRC No. 2010-3247 - Death due to Fentanyl overdose
		Jardine Douglas Klibingaitis - Eligon Inquest
		Karyn Eileen Chase Inquest
		Keith Prescod Inquest
		Kulmiye Hussein Aganeh Inquest
		Matthew Henry Roke Inquest
		Medication Error of an Elderly Palliative Care Patient
		Mladen Mesic Inquest
		MPDRC - Cardiorespiratory failure-hydrops foetalis-tachydysrhythmia
		MPDRC - Intracerebral bleed due to maternal HELLP syndrome
		Paul Thomas Horan Inquest
		PDRC - Death due to suicide by hanging
		PDRC - Death from Hypoxic Ischemic Encephalopathy
		PSRC - Death Caused by Hydromorphone Medication Error
		PSRC - Death due to Acute Propofol Intoxication
		PSRC - Death due to Bilateral Pulmonary Emboli
		PSRC - Death due to chemical-induced pneumonia
		PSRC - Death due to Dilated Cardiomyopathy
		PSRC - Death due to Fecal Peritonitis due to Presumed Colonic Perforation
		PSRC - Death due to hydromorphone toxicity - Infusion Pump
		PSRC - Death Due to Hypotensive Effects of Ramipril and Diltiazam
		PSRC - Death Due to Myocardial Infarction
		PSRC - Death Due to Septic Shock due to Peritonitis
		PSRC - Negative Pressure Wound Therapy (NPWT)
		PSRC No. 2011-14501 - Death due to norepinephrine medication error
		PSRC Report - Death from Hypoglycaemic Event Caused by Erroneous Dose of Insulin Aspart
		Robert Howard Clause Inquest
		Wieslaw Duda Inquest
Category : Paediatrics ‎(7)
		Methusan Vijayaratnam Inquest - Paediatrics
		MPDRC Report - Neonatal Death - Paediatrics
		PDRC - Death Due to Haemorrhagic Shock - Paediatrics
		Tamara Nakic Appendix 1 - Paediatrics
		Tamara Nakic Appendix 2 - Paediatrics
		Tamara Nakic Inquest - Documentation,Health Records,Reporting
		Tamara Nakic Inquest - Paediatrics
Category : Patient Involvement ‎(3)
		Angelina Peluso Inquest - Patient Involvement
		Lana Dale Lewis Inquest - Patient Involvement
		PSRC - Blockage of Hickman Line for Flolan Pump - Patient Involvement
Category : Restraints ‎(6)
		Adeyere Robinson Inquest
		Jeffrey James Inquest
		Mark Alexader Wiens Inquest - Restraints
		Paramjeet Singh Padda Inquest - Restraints
		Peter Lamonday Inquest - Restraints
		Stephane Michaud Inquest - Restraints
Category : Suicide ‎(5)
		Christopher Kelly Robertson Inquest
		Dupont-Daniel Inquest - Implementation of the Jury Recommendations - One Year Report -Suicide
		Dupont-Daniel Inquest - Implementing the Recommendations -Suicide
		Dupont-Daniel Inquest - Jury Recommendations - Dupont-Daniel Inquest December 2007 - Suicide
		Sara Carlin Inquest - Suicide
Category : Transitional Care ‎(13)
		Christopher Mage Inquest - Transitional Care
		Derek McCracken Inquest - Transitional Care
		Eoin Stalker Inquest - Transitional Care
		GLTCRC- Death of 81 year old man due to hospital-acquired pneumonia - Transitional Care
		James O'Brien Inquest - Transitional Care
		Jeffrey Thomas Elliott Inquest - Transitional Care
		Johanne Desrocher Inquest - Transitional Care
		Kerry Nicole Cuddy Inquest - Transitional Care
		Marskell Inquest
		PSRC - Hemodialysis - Transitional Care
		PSRC - Post-surgical T-tube Complication - Transitional Care
		PSRC - Subarrachnoid Hemorrhage - Transitional Care
		Szamko Inquest - Transitional Care
Category : Update from the Chief Coroner ‎(3)
		Memo - Transporting Bodies in Supine Position from Death Scenes - Update from the Chief Coroner
		Organ and Tissue Retention Regulation
		Regulatory Amendments – Organ and Tissue Retention - July 2010

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Annual Committee Reports

	Edit	Title
Year : 2016 ‎(1)
		Geriatric and Long-Term Care Review Committee (2004)
Year : 2014 ‎(4)
		2013-14 PSRC Annual Report - English
		2013-2014 Annual Report - Maternal and Perinatal Death Review Committee
		2014 Annual Report of the Paediatric Death Review Committee and Deaths Under Five Committee
		GLTRC 2013-2014 Annual Report - English
Year : 2013 ‎(1)
		2013 Annual Report of the Paediatric Death Review Committee and Deaths Under Five Committee
Year : 2012 ‎(5)
		2012 Annual Report - Domestic Violence Death Review Committee
		2012 Annual Report - Maternal and Perinatal Death Review Committee
		2012 Annual Report - Patient Safety Review Committee
		2012 Annual Report of the Geriatric and Long-Term Care Review Committee
		2012 Annual Report of the Paediatric Death Review Committee and Deaths Under Five Committee
Year : 2011 ‎(4)
		2011 Annual Report of the Geriatric and Long-Term Care Review Committee
		2011 Annual Report of the Maternal and Perinatal Death Review Committee
		2011 Annual Report of the Paediatric Death Review Committee and Deaths Under Five Committee
		Annual Patient Safety Review Committee Report - 2011
Year : 2010 ‎(3)
		1st Annual Patient Safety Review Committee Report - 2010
		2010 Annual Report of the Geriatric and Long-Term Care Review Committee
		6th Annual Maternal and Perinatal Death Review Committee Report
Year : 2009 ‎(7)
		19th Annual Geriatric and Long Term Care Report
		5th Annual Maternal and Perinatal Death Report
		6th Annual Domestic Violence Death Report
		Maternal and Death Review Committee (2005)
		Maternal and Perinatal Death Review Committee
		Obstetrical Care Review Committee (2004)
		Paediatric Death Review Committee and Deaths Under Five Committee - 2007
Year : 2008 ‎(7)
		3rd Annual Maternal Report - 2008 (Cases from 2006)
		Geriatric and Long-Term Care Review Committe (2005)
		Geriatric and Long-Term Care Review Committee (2006)
		Geriatric and Long-Term Care Review Committee Report - September 2008
		Geriatric Long-Term Care Committte - June 2007
		Maternal and Perinatal Death Review - 2008 (Cases from 2007)
		Paediatric Death Review Committee - Annual Report 2008

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