Quick Hits
Summary
- Call coroner (ON: 1-855-299-4100) for any unnatural or sudden/unexpected death, reportable death (pregnancy, group home, custody), or if there is significant concern that may require investigation (ie from family)
- Not every coroner’s case needs an autopsy
- Surgery within 28 days is NOT an automatic coroner’s case
- If it’s a coroner’s case, do NOT fill out death certificate
Dr. Jennifer Tang
- [email protected]
- Also is a board member of the CMPA, works in Emerg, has a masters of bioethics
“We speak for the dead to protect the living.”
Indications
- 1-855-299-4100, available 24/7/365
- Any unnatural or sudden/unexpected death
- As a result of violence, misadventure, negligence, misconduct or malpractice, by unfair means. Ie accident, suicide, homicide (including overdose, poisoning, accidents)
- During pregnancy or following pregnancy in circumstances reasonable attributed thereto
- from disease or sickness for which they were not treated by a legally qualified medical practitioner
- from any cause other than disease
- under such circumstances that might require investigation (ie if family have expressed care concerns)
- Other reportable deaths:
- deaths in a children’s residence, supported group living environment, psychiatric facility (or after being transferred from one)
- deaths in custody: correctional facility, detention center, committed to secure or open custody
- deaths due to force: peace officer, police, auxiliary police, special constable or First Nations constable
- deaths due to MAID (may change soon - separate coroner’s office for this)
- Explaining to family: “I have to call by law, because X”
What to say
- Who should call? MD or NP preferred
- Decedent ID (spelling) and DOB
- Date and time pronounced
- TGOL if applicable
- PMHX
- Location of body
- Family or police concerns
- Last seen well time
- Why are you calling?
- Your/MRP contact # for call back
- You might be called by the Coroner for request for records (they have a broad right to seize records, but can also ask them to fax this), or for an inquest as an expert or fact witness
Case examples
- 76M with CABG x4, comes in for CP and arrests
- Don’t need to call, most likely an ACS, “if there is a 50% + 1 chance”
- 85M dies in the OR during AAA repair
- Don’t need to call, AAA surgery is inherently very risky
- Previously well 99F, falls, hip #, admitted, died 15 days later of aspiration PNA
- Call, fall in institution NOT considered natural, could be homicide if for example someone pushed them
- 55F found down by friends, drug paraphernalia on scene, dies in the ED
- Call, unexpected and unnatural death
- 83M with known met lung CA, being palliated and dies. Family alleges he was “poisoned” by staff
- Call, need to investigate, obviously based on your clinical judgement as well, based on the severity of the allegations
- 50F quadriplegic dies of catheter related urosepsis. He has a catheter due to being shot when he was 20.
- Call, could be considered homicide! Not natural, and there is no time limit on this
- 78F found outside in a snowbank, brought to ED and pronounced after resus and rewarming
- Call, even though it was “natural”, it could be an accident
- 65M inmate at local jail dies of colon cancer on PCU.
- Need to call because he is an inmate due to Coroner’s Act Section 10
- 80F admitted after fall 2 weeks ago at LTC, brought to ED, had hip #, ORIF, declined, died of urosepsis 2/2 catheter, R1 paged to do death cert. What do you write on the death cert?
- Trick question. Don’t fill it out, call the coroner
- Call dispatch, wait to hear back from coroner physician, coroner attends the hospital and examines the body. Injuries are well imaged and documented, no need for autopsy, body released to funeral home. Chart reviewed, coroner speakers to the family, family expresses concerns regarding care. Coroner reviewed LTC chart, falls risk assessment, actually watches the fall on video tape
- COD: Urosepsis, complications of right hip #, fall from standing height. Manner of death: ACCIDENT
- recommendation to LTC to do quality of care review
- final report released to family in 2-3 mo
- affects vital statistics, life insurance consequences
- Patients declining of natural causes (like cancer or end stage organ failure), or a path #, and they have a fall in hospital or home. Maybe they stumbled, maybe they hit their head, maybe they are on a DOAC. Jennifer Tang’s advice: call coroner and talk it through, “how much do you think it contributed to the death?”
- if unsure, Coroner would probably take the case, could do a CT of the head to confirm
- 55M with end stage cancer, receiving pall care at home via pall nursing and fam doc. Had increasing symptoms, had symptom response kit.
- dosage of HM ordered was 0.5-1mg subcut q4-6h, but concentration was 10mg/mL.
- RN drew up 0.5mL of 10mg/mL concentration, asked family to administer PRN
- so patient actually got 5mg sc HM instead of 0.5-1mg sc HM, patient was opioid naive
- RN flagged this medical error, told MD, MD called coroner. Family was not aware of this medical error.
- Coroner accepted the case, but asked the MD to tell the family first
- Coroner contacted family. Asked police to execute authority to seize the remainder of the syringes from the home
- Post mortem CT and toxicology performed (no autopsy)
- COD: HM toxicity in a patient with end stage cancer
- Manner of death: undetermined (worded this way in the context of therapeutic misadventure)
- Quality of Care review, of the pharmacy (should not have processed this order of 10mg/mL concentration if the dose was 0.5-1mg), lots of learning from this case. Family very grateful that this was investigated, agreed for this case to be shared for learning.
- CREMATION death certificates are actually reviewed by coroners
- COD listed as “respiratory failure” but section 2 had “GSW to neck 15 years ago” and listed as “natural”.
- Coroner calls funeral home and issues a warrant to take possession of the body, coroner contacts police service from 15years ago, autopsy ordered and bullet recovered from the spine (previously unable to due to risk of patient death)
- Bullet matched to a gun in storage, suspect arrested and charged, cold case solved
- Manner of death: homicide
- ICU: 46M transferred from community for ECMO, suspected carbamazepine OD. Very unstable, max pressors, given bicarb, calcium, intralipid, methylene blue, cannulated for ECMO but poor flow, ultimately patient died
- Not natural if carbamazpine OD, body examined, transferred to Toronto Forensic Unit
- Ultimately: 3 people died in one household in four days: patient’s brother and mother as well. All 3x COD: Invasive GAS, Influenza A and COVID.
Mythbusters
- getting the coroner involved is scary
- the coroner performs the autopsies (forensic pathologists)
- every coroner’s case needs/will receive an autopsy (they also have their CT if needed, tox reports, recent CTs in hospital for fractures, sometimes families decline autopsy due to religious/cultural reasons)
- surgery within 28 days is an automatic coroner’s case… not true even though it’s on the death certificate
- the coroner can determine the exact time of death (by some families, generally would say when the body is found)
- coroner’s cases cannot be Trillium Gift of Life candidates ⇒ not true, can still be candidates ie ICU patients
- The medical team/family doc will automatically get a copy of the Coroner’s report… not true, not considered within the circle of care, but Jen Tang will try to ask family if they can share it with family
Autopsies
- what if family requests an autopsy and it isn’t a coroner’s case? reasonable to talk to the coroner on call
- “Consent Autopsy” at HHS, there is actually an Epic order. Also exists at SJH
- Body can be kept by the funeral home until the next morning as long as it is not embalmed.
- Private autopsy? not available currently in Ontario
What is an inquest?
- a public hearing into a death, ensures that the circumstances of a death are known (the 5 W’s)
- multiple death review committees: construction, pediatric, maternal and perinatal, geriatric and LTC, domestic violence, patient safety
- opioid tox deaths, guide public policy for example, death prevention
- Ie Heather Winterstein inquest - her care in the ED at St Catherines, racism or anti-indigenous discrimination
- 2015: Seven Fallen Feathers Inquest in Thunder Bay
- 2022: Working at Heights inquest, occupational legislation
- 2019: Radiohead Stage Collapse in Toronto
- 2024: Barton Street Jail Inquest
- 2015: Rowan Stringer Inquest into concussion (rugby, died from second hit syndrome)
- 2007 Lori Dupont inquest, domestic violence and violence in the workplace