Public fatality inquiries

A public fatality inquiry determines the deceased’s identity and the date, time, place and circumstances of their death.

Recommending an inquiry

Under the Fatality Inquiries Act, the Fatality Review Board reviews deaths where a:

  • person dies while they're detained in a correctional facility, institution, jail or other place – or on its premise
  • person dies in the custody of a peace officer
  • person dies from the use of force by an on-duty peace officer
  • patient under the Mental Health Act dies in a facility or on its premise, even if they weren’t in the custody of that facility
  • child dies under the province's guardianship or in its custody
  • person dies accidentally from something that’s preventable, especially alcohol and drug use, or
  • person dies as a result of their employment or occupation, or in the course of one or more of their former places of employment or occupations

The board may recommend that a death needs a fatality inquiry, to help:

  • prevent similar deaths in the future
  • protect the public, or
  • clarify the case's circumstances

The board's recommendation must be approved by the Minister, who calls the inquiry.

Note: The Minister can call an inquiry without the board’s recommendation.

Fatality Review Board

Pre-inquiry conference

This conference is the first step in any fatality inquiry, ensuring that all parties understand an inquiry’s:

  • purpose
  • issues, and
  • procedures

No witnesses are called and no evidence is introduced at pre-inquiry conferences, which are open to the public and media.

Fatality inquiry

An inquiry into a death happens after the:

  • police and Office of the Chief Medical Examiner (OCME) have completed their investigations, and
  • courts have resolved any related criminal charges, including appeals

A fatality inquiry is held before a judge at the Provincial Court. Each inquiry is open to the public, unless the presiding judge orders that parts be held in private.

To request a fatality inquiry

  1. write a letter of concern about a specific death
  2. address the letter to the Fatality Review Board
  3. send the letter to (ie, in care of) the OCME

The board will decide whether or not to recommend an inquiry.