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Caseload Overview

Table 1 Number of deaths investigated by Coroners or Medical Examiners, by year, Provinces and Territories, 2006 to 2008Table 1
Number of deaths investigated by a C/ME, by year, Provinces and Territories, 2006 to 2008

A total of 98,623 cases were successfully loaded onto the CCMED for the period 2006 to 2008. The majority of these cases are from Ontario, followed by Quebec, Alberta and British Columbia. From Table 2, roughly 15% to 16% of deaths were investigated by a C/ME annually, although this varied greatly by province and territory, from a high of over 40% in the Northwest Territories, to a low of around 7% in Quebec. Elsewhere, the intervention of a C/ME was required in 11% to 30% of deaths annually. New Brunswick had the highest rate of investigation of all provinces, both in terms of the percentage of all deaths investigated by a C/ME (around 25% annually) and relative to its population (2.1 coroner's investigations per 1,000 population), where it led all jurisdictions; Quebec had the lowest for both rates.

Table 2 Deaths investigated by Coroners or Medical Examiners as a percentage of all deaths, by year,Provinces and Territories, 2006 to 2008Table 2
Deaths investigated by a C/ME as a percentage of all deaths, by year, Provinces and Territories, 2006 to 2008

In the seven provinces, the annual C/ME caseloads were relatively stable over the three years, both in terms of raw number and the percentage of deaths investigated. In the two territories, the number of deaths investigated by the coroners seems somewhat more variable, however in each case there is general agreement for two of the three years. For these reasons, much of the information presented in what follows will be expressed as aggregates for the three-year period 2006 to 2008.

Table 3 presents the number of deaths investigated by a C/ME, by age and sex of the deceased. In general, 80% or more of the cases involved persons aged 30 to 89 years of age, with male decedents accounting for almost two thirds of C/ME caseload and investigations involving males age 50 to 69 representing the greatest share of C/ME cases. The latter holds true, in all provinces and territories except New Brunswick and Ontario, where males aged 70 to 89 represented the greatest share of C/ME caseload.

Table 3 Number of Coroners or Medical Examiners investigations, by sex and age group, Provinces and Territories, 2006 to 2008Table 3
Number of C/ME investigations, by sex and age group, Provinces and Territories, 2006 to 2008

Among females, investigations involving those aged 70 to 89 represented the greatest share of C/ME cases, although this result is driven by Ontario, and to a lesser extent New Brunswick and Saskatchewan; elsewhere, caseload share was similar between the 50 to 69 and 70 to 89 age groups.

In all provinces and territories and in all age groups, except those aged 90 and over, male decedents, subject to a C/ME investigation, outnumber their female counterparts. From Table 4, with some exception in Prince Edward Island and the territories, the same observation holds true for the percentage of deaths investigated by a C/ME. Persons aged 15 to 29 years were the most likely subjects of a C/ME investigation in both males and females, where between 72% and 92% of deaths were C/ME cases, depending on province or territory. However, it was the 30 to 49 and 50 to 69 age groups that showed the greatest disparities between males and females: the death of a male in these age groups was between 1.4 and 2.9 times more likely to have been the subject of a C/ME investigation than the death of a female.

Table 4 Deaths investigated by Coroners or Medical Examiners as a percentage of all deaths, by sex and age group, Provinces and Territories, 2006 to 2008Table 4
Deaths investigated by a C/ME as a percentage of all deaths, by sex and age group, Provinces and Territories, 2006 to 2008

The differences observed by age, sex and province or territory in this section are the result of several factors, including the structure of the provincial and territorial populations, socio-economic factors and the circumstances under which the different provincial and territorial C/MEs are mandated to investigate deaths. The following sections will attempt to use the contextual data of the CCMED to provide a better perspective on these differences.

Manner of Death

There are five manners of death commonly used: natural, accident, suicide, homicide and undetermined. Some jurisdictions also include unclassified, but with different meanings; in Alberta, unclassified deaths are those where alcohol was a factor in the death, in the Northwest Territories, unclassified deaths refer to non-human remains, while in Ontario, unclassified deaths refer to skeletal remains where it is not possible to determine a cause of death. For the purposes of this report, all unclassified deaths for Alberta were recoded to "undetermined"; for Ontario and the Northwest Territories, unclassified deaths are excluded from the CCMED. A small number of cases in Saskatchewan coded "unclassified" were excluded from the tabulations where noted.

The figures in Appendix A present the annual caseloads, by manner of death, for each province and territory. In general, the caseload distributions are very stable over the three years, with some exception in the territories.

Table 5 Distribution of Coroners or Medical Examiners investigations, by manner, Provinces and Territories, 2006 to 2008Table 5
Distribution of C/ME investigations, by manner, Provinces and Territories, 2006 to 2008

Table 5 provides a breakdown of cases by manner of death, by province and territory for the period 2006 to 2008. Over 60% of all C/ME investigations led to a determination of death by natural causes, followed by accidental death at 24%, suicides, undetermined and homicides. This pattern holds true for most of the provinces and territories. Quebec had a more balanced caseload than the other provinces, with natural deaths accounting for 36% of investigations, followed closely by accidents (32%) and suicides (28%). Elsewhere, there seems to be an east-west disparity with respect to caseload distribution: Prince Edward Island, New Brunswick and Ontario have similar distributions in the East; and the three western provinces and two territories have similar distributions.

Appendix B examines the distribution of caseload, by manner of death, for individual age groups. Further refinement of the youngest age groups presented in Tables 3 and 4 was done to examine differences in infant, preschool and school-aged children categories. In general, natural causes was the predominant manner of death in people aged 0 to 23 months and people aged 39 years or older, with accidental deaths representing the second highest proportion of deaths in these age groups. Exceptionally, in deaths of people aged 0 to 11 months, the manner of death could not be determined for over 25%.

Among those aged 2 to 29 years, accidental deaths accounted for the largest percentage of C/ME investigations, with natural deaths accounting for the second largest share of caseload. The lone exception was for decedents aged 15 to 29, where suicide accounted 25% of deaths investigated by a C/ME, and natural deaths only 11%. Not surprisingly, this was also the group for which a C/ME investigation was most likely.

As mentioned previously, even though provincial and territorial C/MEs share a common goal, their practice can vary according to different legislations and/or definitions of C/ME concepts. The remainder of this section will focus individually on each manner of death in an effort to tease out some of these differences.

Natural Deaths

Table 6 Distribution of natural deaths  investigated by a  Coroner or Medical Examiner, by sex and age group, Provinces and Territories, 2006 to 2008Table 6
Distribution of natural deaths investigated by a C/ME, by sex and age group, Provinces and Territories, 2006 to 2008

Deaths categorized as natural are those where a disease initiated the chain of events ending in death. Among deaths that occurred in 2006 to 2008, C/MEs investigated 59,709 deaths that were determined to be natural. Statistics for this period (Table 6) show that roughly 60%—over 70% in the territories—of these were male decedents. This is similar to the male-female split observed for all C/ME cases. Generally, for both sexes, the majority of deaths investigated are in age groups 50 to 69 and 70 to 89. Natural deaths in people aged 90 years and over are more often deaths of females.

To better understand the circumstances under which the coroners and medical examiners investigate natural deaths, it might be informative to look at the place of death. Table 7 shows that, not surprisingly, most natural deaths occur in a private residence or medical services facility. But what is interesting is that almost half (48%) of the natural deaths investigated by a C/ME occurred in a hospital, health professional's office, nursing home, long-term care facility or hospice, and that this percentage varies considerably by province and territory, from a low of 24% in the Yukon to a high of 87% in New Brunswick. This observation points perhaps to jurisdictional differences as to when, in a medical setting, the intervention of a C/ME is required. For example, in Ontario every tenth death occurring in a long term care facility must be investigated by a coroner.

Table 7 Distribution of natural deaths investigated by a Coroner or Medical Examiner, by place of death, Provinces and Territories, 2006 to 2008Table 7
Distribution of natural deaths investigated by a C/ME, by place of death, Provinces and Territories, 2006 to 2008

Accidental Deaths

Deaths categorized as accidental are those where an injury initiates the chain of events ending in death and there is no element of intent in the circumstances leading to the injury. Among deaths that occurred in 2006 to 2008, C/MEs investigated 23,097 accidental deaths. From Table 8, 65% of these were male decedents; in the territories and Alberta, males accounted for over 70% of accidental deaths. Like natural deaths, the male-female split for accidental deaths is similar to that observed for all C/ME cases. Generally, males aged 15 to 69 account for just under a half or more of all such deaths (44% in Saskatchewan to around 70% in the Northwest Territories); exceptionally, in Ontario, this age-sex group represented just over a third of all accidental deaths, and males and females aged 70 to 89 years accounted for 17% and 18% of accidental deaths respectively. Like natural deaths, accidental deaths in people aged 90 years and over are more often deaths of females, owing to the structure of the population.

Table 8 Distribution of accidental deaths investigated by a Coroner or Medical Examiner, by sex and age group, Provinces and Territories, 2006 to 2008Table 8
Distribution of accidental deaths investigated by a C/ME, by sex and age group, Provinces and Territories, 2006 to 2008

To gain greater insight into the nature of accidental deaths, it might be interesting to look at the activity in which the deceased was engaged at the time of the event leading to death. Table 9 provides the distribution of accidental deaths by activity. Note that for New Brunswick and Saskatchewan, this information is not routinely collected, and British Columbia seems to code activity as not applicable for most of its cases. Looking at the coroners' narratives for the latter, it seems that "not applicable" is used in instances of traffic accidents and accidental deaths involving the use of drugs and/or alcohol.

Elsewhere it seems that this information was rarely specified, with the exception of the territories. The end result is that this information has limited analytic value, but can be used along with other information in the database, like information regarding the circumstances and conditions surrounding the events leading to death and the use of safety devices, to help researchers identify cases of potential interest.

Table 9 Distribution of accidental deaths investigated by a Coroner or Medical Examiner, by activity at the time of event leading to death, Provinces and Territories, 2006 to 2008Table 9
Distribution of accidental deaths investigated by a C/ME, by activity at the time of event leading to death, Provinces and Territories, 2006 to 2008

Table 10 presents the distribution of accidental deaths by circumstances of injury. Deaths involving falls or jumps accounted for over a quarter of the accidental deaths investigated by a C/ME. This result is driven by Ontario, where fall or jump was provided as a circumstance of injury in 45% of accidental deaths. In fact, in Ontario, nearly 6 in 10 (not shown) of the accidental deaths involving women involved a fall or jump. Elsewhere, deaths that involved occupants of standard road vehicles (half of the deaths in Alberta) and drug and alcohol poisonings (nearly one third of deaths in British Columbia) accounted for important portions of the accidental deaths investigated by a C/ME. For a significant number of cases in Saskatchewan, Quebec, Prince Edward Island, Yukon and the Northwest Territories no circumstances of injury were provided.

Table 10 Distribution of accidental deaths investigated by a Coroner or Medical Examiner, by circumstances of injury, Provinces and Territories, 2006 to 2008Table 10
Distribution of accidental deaths investigated by a C/ME, by circumstances of injury, Provinces and Territories, 2006 to 2008

Suicides

All deaths where a self-inflicted injury initiates the chain of events ending in death and where the decedent intends to cause their own death are classified as suicides. After natural and accidental manner of death, suicide is the manner of death most often investigated by coroners and medical examiners.

Among deaths that occurred in the period 2006 to 2008, C/MEs investigated 10,217 suicides. Males accounted for nearly three quarters or more of suicides in all provinces and territories (73% in Saskatchewan to 90% in the Yukon), and with some exception, the highest proportion of C/ME cases deemed suicide among the age groups belonged to those aged 30 to 49 years. In the Northwest Territories, however, decedents aged 15 to 29 accounted for half or more of all suicides. Unlike natural and accidental deaths, men aged 90 and older accounted for more suicides than their female counterparts.

Table 11 Distribution of suicides investigated by a Coroner or Medical Examiner, by sex and age group, Provinces and Territories, 2006 to 2008Table 11
Distribution of suicides investigated by a C/ME, by sex and age group, Provinces and Territories, 2006 to 2008

The circumstances of injury enable us to identify the mechanism of death in the case of suicides. Tables 12a and 12b provide the circumstances of injury for deaths deemed to be suicides by coroners and medical examiners, for men and women respectively. Note that Saskatchewan does not routinely collect this information, and it is rarely provided in the case of suicides in Prince Edward Island, Quebec, and to a lesser extent the Yukon. In cases where other circumstances are specified, often (89% of instances; 98% of instances in Ontario and in Alberta, and 64% of instances in British Columbia) reference is made to hanging or asphyxiation, and should be assigned one of the standard codes. With that in mind, where circumstances are provided, strangulation (hanging and other forms of self-asphyxiation), firearms, poisoning / acute drug toxicity (intentional drug overdose) and fall or jump are most often cited, though the order of importance varied by sex and jurisdiction. Strangulation was most often a circumstance of death in male suicides (over 40% in Ontario), followed by drug overdose and use of a firearm. For women, drug overdose was most often a circumstance of death (cited in over half of female suicides in both Alberta and British Columbia), followed by strangulation and a smaller proportion attributed to fall or jump.

Table 12-A Distribution of suicides investigated by a Coroner or Medical Examiner, by circumstances of injury, men, Provinces and Territories, 2006 to 2008Table 12-A
Distribution of suicides investigated by a C/ME, by circumstances of injury, men, Provinces and Territories, 2006 to 2008

Table 12-B Distribution of suicides investigated by a Coroner or Medical Examiner, by circumstances of injury, women, Provinces and Territories, 2006 to 2008Table 12-B
Distribution of suicides investigated by a C/ME, by circumstances of injury, women, Provinces and Territories, 2006 to 2008

Homicides

Homicides include all deaths where an injury initiates the chain of events ending in death and there is evidence to indicate some intent on the part of another individual to cause harm. Among deaths that occurred in the period 2006 to 2008, C/MEs investigated 1,554 homicides, making it the least frequently assigned manner of death. Males accounted for three quarters of all homicides, with males in the 15 to 29 age group representing the victims of one third of all homicides. Among women, those aged 30 to 49 years represented the largest share of victims.

Table 13 Distribution of homicides investigated by a Coroner or Medical Examiner, by sex and age group, Provinces and Territories, 2006 to 2008Table 13
Distribution of homicides investigated by a C/ME, by sex and age group, Provinces and Territories, 2006 to 2008

As death and the event leading to death sometimes occur in different locations, the place of death provides little insight into such deaths. For example, death often occurs or is pronounced in a hospital following an injury sustained elsewhere. Table 14 presents the distribution of homicides by place of the event leading to death type. Where this information is provided—Saskatchewan does not routinely collect this information, and it is not specified elsewhere—the largest share of homicides occurred in private residences, followed by the countryside, which includes remote areas and provincial and national parks; recreational, public, entertainment and commercial areas; and, transport areas, which include roadways, sidewalks, railways, air, water and land transportation terminals and some transport vehicles.

Table 14 Distribution of homicides investigated by a Coroner or Medical Examiner, by place of event leading to death, Provinces and Territories, 2006 to 2008Table 14
Distribution of homicides investigated by a C/ME, by place of event leading to death, Provinces and Territories, 2006 to 2008

For more comprehensive information on homicide, researchers might be better served using data that incorporate police and C/ME findings. That being said, the CCMED does provide a convenient source of information for examining certain topics that cut across manners of death, for example deaths involving firearms, which could involve any combination of homicides, suicides, accidental and undetermined deaths.

Undetermined Deaths

Undetermined deaths are those where there is significant doubt as to which of the previous manners the death should be attributed. Among deaths that occurred in the period 2006 to 2008, C/MEs investigated 3,853 deaths where it was not possible to determine the manner of death. Deaths of people aged 30 to 69 years of age accounted for over 70% of all such deaths. As was the case for natural and accidental deaths, the decedent is male in 63% of C/ME cases where the manner of death could not be determined.

Table 15 Distribution of Coroner or Medical Examiner investigations where the manner of death is undetermined, by sex and age group, Provinces and Territories, 2006 to 2008Table 15
Distribution of C/ME investigations where the manner of death is undetermined, by sex and age group, Provinces and Territories, 2006 to 2008

It might be difficult to understand the circumstances under which the manner of death could not be determined. Review of the C/ME's narrative (currently unavailable for New Brunswick and Quebec) and information regarding the cause and conditions of death from the death certificate might reveal the exact nature of debate, for example accidental death vs. suicide. Closer study of a sample of these cases indicates that they are predominantly a mixture of cases where medication or drug overdose occurred, or situations where these and/or alcohol were used; sudden and unexplained deaths of infants; and, situations where elements that would suggest intentional harm or injury were present, but where there was insufficient evidence to conclude intent.

Inquests and Recommendations

Inquests are held in order to inform the public of the circumstances surrounding a specific death and to make policy recommendations to prevent similar deaths from occurring in the future. The CCMED does not track the number of recommendations that were made for a specific case or the details of specific recommendations. However, it does keep track of whether or not recommendations were made for each case by the C/ME or by a jury, provided this information is available from the province or territory. The availability of such information strengthens the preventive role of the CCMED. This data can be of great assistance for researchers and other C/MEs to search for similar cases and learn from the experience of other jurisdictions.

Among deaths investigated by a C/ME that occurred in the period 2006 to 2008, there were a total of 791 for which an inquest was, or would be, held. This represents less than 1% of all C/ME cases during this time. While Ontario held the highest number of inquests (595), the Yukon had the highest percentage of cases for which inquests were held (almost 2%), although inquests in the territories and Prince Edward Island were infrequent. And while inquests were more frequent in cases of natural (278) and accidental (266) deaths, an inquest was most likely in the case of a homicide (3.7%) or death where the manner could not be determined (3.2%). These last results are driven by Ontario, where inquests were held in 6.4% of homicides and 6.8% of undetermined deaths.

Table 16 Number and percentage of Coroner or Medical Examiner cases where inquests were held, by manner, Provinces and Territories, 2006 to 2008Table 16
Number and percentage of C/ME cases where inquests were held, by manner, Provinces and Territories, 2006 to 2008

Recommendations were made in 1,225 C/ME cases over the period 2006 to 2008. Quebec accounted for over half of these, with recommendations made in 845 cases, however it is in the Northwest Territories where recommendations were most likely (10% of cases). Recommendations are most likely in the case of an accidental death—recommendations were made in 3.1% of accidents investigated by a C/ME—though the percentage varies greatly by province and territory.

Table 17 Number and percentage of Coroner or Medical Examiner cases where recommendations were made, by manner, Provinces and Territories, 2006 to 2008Table 17
Number and percentage of C/ME cases where recommendations were made, by manner, Provinces and Territories, 2006 to 2008

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