The coroner may make recommendations to prevent a similar death in the future. Recommendations made by a coroner are brought to the attention of the appropriate people, agencies, departments or ministries of government by the Chief Coroner. The coroner may work with the police, pathologists, investigators from Occupational Health and Safety and the Transportation Safety Board, dental experts, anthropologists and neuropathologists. Each enquiry varies. It usually takes four months for documentation, the autopsy report and the Declaration of Coroner to be available.
Inquests are open to the public and are similar to a judicial process.
Witnesses are summoned by the coroner to give evidence, under oath, on their knowledge of the death. The evidence is given before a six-person jury summoned at random from the community where the inquest is held. Witnesses include any persons able to give material evidence on the cause of death or any other matter being examined at the inquest. After hearing the evidence, the jury gives its verdict by stating the name of the deceased, the time, place and cause of death and any recommendations to help avoid similar deaths. These recommendations are brought to the attention of appropriate people, agencies, departments or ministries of government by the Chief Coroner.