A lot of them at the beginning were newspaper, television and radio coverage across Canada about our press conference last week and related articles since July when the Transport Canada Accident Reconstruction Report came out and the RCMP Report in November. There were also many website documents about Inquests that have taken place in New Brunswick after accidental deaths.
Deep inside some of these documents were very interesting bits of information that we would never have known because nobody will really tell you and because the Coroner's Act, which governs Inquests, is so complicated that you need a law degree to understand it. We are just ordinary people and it's way beyond our understanding to read all that legal stuff, as it is for most.
So we were glad to stumble upon a 2003 pamphlet called Coroner's Inquest Nurse-to-Nurse Legal Information from the Nurses Association of New Brunswick (NANB) that gave all kinds of easy to understand information about Inquests in New Brunswick and we thought we should share the questions and answers with everyone.
Click here to view Coroner's Inquest Nurse-to-Nurse Legal Information in PDF format
Will All Cases Investigated by a Coroner Proceed to an Inquest?
No, all cases investigated by a Coroner will not proceed to an inquest. Of the 1,400 to 1,500 cases investigated annually in New Brunswick, very few proceed to an inquest. During the course of the Coroner’s investigation, the Coroner’s role includes obtaining information, seizing documents, answering questions about the death and making a determination as to whether or not an inquest is warranted. In most cases, an inquest is deemed not to be warranted but an investigation is conducted and a report is prepared.
What is an Inquest?
An inquest is a public inquiry into the issues surrounding a death where there is some question about the circumstances under which the death occurred. For example, where a person has reason to believe that another person has died as a result of violence, misadventure, negligence, misconduct, malpractice, any cause other than disease or natural causes or under circumstances which require investigation, that person is obligated by law to notify a Coroner of the facts and circumstances relating to the death. The Coroner, after investigation, determines whether an inquest is necessary. An inquest seeks to answer the questions of “who died,” “when,” “where,” “how” and “by what means.” In addition to ascertaining these factual issues, determining whether any remedial or preventive action can or should be taken to prevent similar deaths from occurring in the future is a primary purpose of inquests.
An inquest is not a trial and there is no defendant or accused. In New Brunswick, inquests are conducted by a Coroner and a lay jury of five persons. A provincial statute, the Coroners Act, regulates the appointment and conduct of Coroners and governs the proceedings of the inquest itself. Coroners are not judges.
Who Will Be at the Inquest?
Generally, persons who have an interest in the outcome of the inquest (with or without their lawyers), summoned witnesses (with or without their lawyers), the Coroner, the Coroner's lawyer, five jurors, a court reporter, other Coroners to assist the Coroner as required, and interested members of the public (including media) will be present at an inquest.
What Happens During an Inquest?
The Coroner is in charge of the proceedings during an inquest. The Coroner uses the services of a lawyer, who is usually a crown prosecutor, to lead the questioning of witnesses and to provide the Coroner with advice on legal issues. Inquests are held in a variety of locations. Some settings may be or may resemble courtrooms while others may be less formal. The evidence presented during the inquest is either recorded or transcribed by a shorthand stenographer. Witnesses give testimony under oath.
Lawyers for persons who have an interest in the outcome of the inquest are asked by the Coroner to identify themselves and the persons for whom they are acting, for the record. These lawyers may submit written questions to the Coroner's legal advisor to be asked of witnesses. Lawyers for interested parties present and on the record are usually seated at the front with the Coroner's legal advisor.
Since an inquest is a public hearing, any member of the public may attend unless the public is excluded by the Coroner pursuant to section 21 of the Coroners Act. The exclusion of the public does not occur often.
At the beginning of the inquest, the Coroner gives a brief summary of the facts already known about the death and explains the procedures that will be followed during the inquest.
The Coroner, in conjunction with a lawyer, determines the order in which witnesses are called. Each witness is sworn to tell the truth. The lawyer for the Coroner leads off the questioning followed by the jurors and the Coroner. The Coroner then invites those lawyers who are on the record to submit written questions to be asked of the witness by the Coroner's legal advisor. The lawyer for the Coroner or the Coroner or the jurors may also ask supplementary questions. After completing testimony, the witness is excused and may either join the public section for the remainder of the inquest or leave.
After the witnesses who have been summoned to testify have given their evidence, it is the practice of the Coroner to invite anyone present who believes they have relevant evidence to come forward.
If people do come forward, the inquest is adjourned for a short period to allow the lawyer for the Coroner to interview these new witnesses. If it is determined that their evidence is relevant, these new witnesses are called to testify.
Once all witnesses have been called and all evidence has been presented, the Coroner charges the jury to examine all the evidence, to make its findings of fact and to consider making recommendations. The jury then adjourns to a jury room to make decisions regarding the questions of who died, when, where, how and by what means and to make recommendations regarding prevention of injury or death in similar circumstances. The exhibits accompany the jurors to the jury room. The jury makes its decisions by majority vote. Once the jury has completed its work, the jurors return to the hearing room and the findings are read out and are recorded.
The record of the inquest is forwarded to the office of the Chief Coroner who sends the recommendations and his comments to any department, agency, municipality or person the Chief Coroner believes should be concerned with the subject matter of the recommendations. Although the recommendations are not legally binding, they are known to have great persuasive powers for change.
