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OHRC Submission re Proposal to Amend the Coroners Act: Annual Reviews of Deaths in Correctional Institutions

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January 19, 2026

Introduction

The Ministry of the Solicitor General (SOLGEN) is proposing significant changes to how the Office of the Chief Coroner (OCC) reviews deaths that occur in Ontario’s correctional institutions. Mandatory coroner’s inquests for individual non-natural deaths that occur in correctional institutions, or that occur elsewhere but were caused by an injury in a correctional institution, would be replaced with a mandatory coroner-led annual review that examines these deaths together. Families could request an individual inquest into the death of a loved one in addition to the annual review, if desired.

Deaths that occur in correctional institutions warrant the highest level of scrutiny. People in Ontario’s correctional system are subject to complete state control over their lives. Where one of these lives is lost, it is incumbent on us as a society to probe into why and ask what should be done to prevent the same thing from happening again. This is especially true from a human rights perspective, given that Ontario’s correctional system has long been marked by well-documented patterns of discrimination, particularly for Indigenous and Black prisoners, prisoners with mental health disabilities, and women. The loss of life must also be understood in the context that over 80% of people in Ontario’s provincial correctional institutions are on remand, meaning that they are awaiting trial and have not been found guilty of a crime.[1]

The OHRC has long called for independent oversight and monitoring of Ontario’s correctional system. While the OHRC maintains this position, the OHRC sees potential for the proposed shift to annual coroner-led reviews to enhance transparency, oversight and accountability relating to deaths that occur in Ontario’s correctional institutions – all of which are sorely needed. To achieve this potential, the proposed annual review process must operate to ensure human rights concerns are properly addressed, and that valuable elements from the present system of mandatory individual inquests are not lost. Accordingly, the OHRC recommends:

  1. The annual reviews should examine all deaths in Ontario’s correctional institutions, not just non-natural deaths; 
  2. The Coroners Act should require that the annual reviews include analysis based on relevant Human Rights Code grounds and sociodemographic data; 
  3. The annual review process should preserve the ability of key stakeholder groups to actively participate; 
  4. The annual review process should require multi-year tracking of recommendations made, official responses, and analysis of implementation; 
  5. Information from the annual review should be made publicly available in a timely and effective manner; and
  6. Parties with an interest in the death, including families, individuals and organizations, should have the ability to request an individual inquest.

Human Rights and Ontario’s Correctional System

Ontario’s Human Rights Code

The Ontario Human Rights Code [2] (the “Code”) is a provincial law that protects people from discrimination because of protected grounds such as disability, race, sex (including pregnancy and breastfeeding), sexual orientation, gender identity and creed. The Code applies to various social areas, including employment, contracts, goods, services, and facilities in Ontario. The Code has primacy over all other laws in Ontario (unless the legislation expressly includes an exemption from the Code).  Discrimination contrary to the Code can occur in different ways, including when people are treated differently because of a characteristic protected by the Code, or when practices or policies appear neutral but have harmful effects for people with particular Code characteristics.

Ontario’s correctional system, including related corrections legislation, is subject to the Code[3].

The Ontario Human Rights Commission

The Ontario Human Rights Commission (OHRC) is a statutory human rights body established under the Code. It is responsible for promoting and advancing human rights and preventing discriminatory practices in Ontario. Our mandate places a particular emphasis on addressing systemic discrimination, which refers to patterns of behaviour, policies and/or practices that are part of the social or administrative structure of an organization, and that create or perpetuate a position of relative disadvantage for persons protected by the Code. The OHRC’s functions include examining legislation for compliance with the Code. 

The OHRC is recognized in Ontario and internationally as an expert in human rights and correctional policy. The OHRC's submissions are based on years of extensive work advocating for Ontario’s correctional practices to meet the government’s obligations under the Code, the Canadian Charter of Rights and Freedoms, and international law, including: touring Ontario’s correctional institutions to monitor and report on conditions; interviewing prisoners and front-line correctional staff and management; reviewing and providing submissions on correctional legislation, regulations, policies, procedures, practices, and training; obtaining and analyzing data regarding correctional operations; and pursuing and participating in litigation relating to Code and Charter violations at the Human Rights Tribunal of Ontario and courts. The OHRC’s work has addressed human rights issues in Ontario’s correctional system relating to matters such as the use of segregation and restrictive confinement; lockdowns; the treatment of women prisoners, transgender prisoners, and prisoners with mental health disabilities; access to healthcare and other services; and prisoner deaths.

In addition, the OHRC has participated in coroner’s inquests, including those relating to deaths in corrections [4]. 

The Proposal

On December 17, 2025, SOLGEN announced a proposal to replace individual inquests for all non-natural deaths in correctional institutions with a mandatory coroner-led annual review of these deaths [5].

Under the current system of individual inquests, parties who have a substantial and direct interest in the death present evidence to a five-member jury panel [6]. At the end of the inquest proceeding, the jury makes conclusions about the facts of the death and may make recommendations to prevent further deaths [7]. The inquests only begin after other investigations (e.g., criminal investigations) are complete. The typical timeframe for completion is five to seven years after a death occurred [8]. 

Under the proposed new system, deaths in Ontario’s correctional institutions would instead be examined through mandatory coroner-led annual reviews, where the coroner leading the review would be supported by an advisory committee composed of experts and stakeholders [9]. The coroner and committee would consider systemic issues underlying deaths and make recommendations to prevent further loss of life within the corrections sector [10]. Families would have the opportunity to participate in the annual review process and still be able to request an individual inquest into the death of a loved one [11].

A stated aim of the proposal is to help “[a]ddress the challenges faced by families, individuals and organizations participating in an inquest proceeding many years after a traumatic event, including: re-traumatization of participants, changes in processes and policies that make the issues raised at the inquest redundant, changes in personnel that challenge the ability to locate and identify appropriate witnesses and the negative impact that the passage of time has on witnesses' abilities to recall the events in question.”[12]

OHRC Key Recommendations

The OHRC acknowledges the merit of the proposed amendments to the Coroners Act to require mandatory coroner-led annual reviews of deaths in Ontario’s correctional institutions, subject to the annual review process operating in a way that ensures human rights concerns are properly addressed and that preserves valuable elements from the current system of mandatory individual inquests.

There are serious and longstanding concerns regarding the absence of transparency, oversight and accountability in the operation of Ontario’s correctional system. A troubling aspect of this has been the lack of clear, reliable and consistent tracking and reporting about deaths in Ontario’s correctional institutions [13]. The numbers that are available nonetheless reveal that deaths in corrections are a significant problem. The OCC’s Expert Panel on Deaths in Custody, which was mandated to review deaths of people in correctional custody between 2014 and 2021 reported that, “there were 186 in-scope deaths during this period, and the trend line has risen dramatically over the period, from 19 deaths in 2014, to 25 in 2019, and 46 in 2021.”[14] A particularly tragic feature of these deaths is the fact that experts examining Ontario’s correctional system have repeatedly noted that many could have been prevented.[15]

The OHRC has consistently supported independent oversight of Ontario’s correctional system and continues to do so. The OHRC recognizes that the proposed transition from individual inquests to mandatory coroner-led annual reviews could offers several potential advantages, including: 

  • Enhance transparency in the tracking and reporting of deaths in Ontario’s correctional institutions;
  • Identify trends and systemic issues contributing to deaths in Ontario’s correctional institutions, including disproportionate impacts based on grounds protected by the Code, as well as measures that could prevent future deaths; and
  • Offer increased accountability by monitoring the implementation of recommendations made to prevent future deaths.

For the proposal to achieve these potential advantages, the OHRC makes the recommendations below:

  1. The annual reviews should examine all deaths in Ontario’s correctional institutions, not just non-natural deaths.

The current proposal recommends mandatory coroner-led annual reviews to examine all non-natural deaths in correctional institutions in Ontario. The OHRC considers it essential that these annual reviews cover all deaths in correctional custody in Ontario, rather than restricted to non-natural deaths. This proposed amendment is mot without precedent. Before 2009, the Coroners Act included a requirement for inquests in the cases of all in-custody deaths.[16]

The “natural death” or “death from natural causes” classification refers to circumstances where there is an underlying medical cause for the death and where injury did not cause or substantially contribute to the death [17]. While there have been ongoing challenges determining definitive figures, natural deaths are consistently reported as a significant portion of deaths in Ontario’s correctional institutions, ranging from a quarter to over half of all deaths.[18]

Deaths classified as “natural” within Ontario’s correctional system have consistently been associated with significant challenges regarding access to medical care, emergency responses, medication dispensing, medical documentation practices, conditions of confinement, and access to family and social supports.[19] These concerns are particularly relevant from a Code perspective, as deficiencies in service availability and quality may increase risk for vulnerable individuals, including those with physical or mental health disabilities and women. In addition, the cost of these issues is disproportionately experienced by communities who are overrepresented in Ontario’s corrections system, such as Indigenous and Black people.[20]

The OHRC sees the potential for mandatory annual reviews to enhance transparency and oversight regarding deaths in Ontario’s correctional system. However, omitting such a significant category of deaths, especially knowing that they are linked to systemic issues in corrections, leaves a major gap in transparency and oversight and significantly limits the potential impact of the annual review towards preventing future deaths.

  1. The Coroners Act should require that the annual reviews include analysis based on relevant Human Rights Code grounds and sociodemographic data.

The Coroners Act should also be amended to expressly require that the annual review process include analysis based on relevant Code grounds and sociodemographic data with the purpose of identifying patterns, disparities and trends in mortality and the circumstances surrounding deaths. [21]

Such analysis is especially important given the overrepresentation and/or heightened vulnerability of prisoners in Ontario’s correctional system who are associated with Code-grounds, such as Indigenous and Black prisoners, prisoners with mental health disabilities, and women, as described above. 

This opportunity to undertake and report on such analysis is one of the main advantages that could arise from the proposed shift to mandatory annual reviews.

  1. The annual review process should preserve the ability of key stakeholder groups to actively participate.

In the present system, mandatory individual inquests into non-natural deaths present one of the only moments where the conditions in and internal operations of Ontario’s correctional facilities are exposed to scrutiny, including for key stakeholder groups like human rights and prisoners’ rights organizations. Ontario’s correctional system is otherwise exceptionally closed off and operates without any independent or external oversight – in contrast to others like the Correctional Service of Canada, which has the Office of the Correctional Investigator serving as an independent ombudsman for federally sentenced people.[22]

The proposed shift from individual inquests to mandatory annual reviews should not come at the cost of transparency and participation. Accordingly, the OHRC recommends that any move towards the annual review model preserve mechanisms for key stakeholder groups to be involved in aspects of the process such as reviewing and contributing to evidence and making submissions. 

  1. The annual review process should require multi-year tracking of recommendations made, official responses, and analysis of implementation.

The persistent issue of government’s inadequate implementations of recommendations aimed at preventing deaths in Ontario’s correctional institutions – whether proposed by inquest or oversight bodies - has been well documented.[23] A consistent gap exists between official government statements indicating adherence to recommendations or legal requirements and findings from independent investigations, which often reveal that resulting changes are superficial, procedural or insufficiently put into practice. [24] As a result, similar recommendations are made repeatedly across multiple inquests and reports spanning many years. Furthermore, there is currently no efficient system for tracking recommendations, monitoring official government responses, or for evaluating the effectiveness of implementation.[25]

The proposed shift to annual reviews of deaths in Ontario’s correctional institutions presents a significant opportunity to help address this problem. The OHRC proposes that a required feature of the new system be multi-year tracking of recommendations (including proposed timelines), official responses, and analysis of whether recommendations have been effectively acted upon. This approach would promote accountability for preventing future deaths in Ontario’s correctional institutions.

  1. Information from the annual review should be made publicly available in a timely and effective manner

To maximize the value of the annual review, it is crucial that information from the reviews be shared publicly in manner that is timely and allows families, advocates, researchers, the media and the broader public to engage. Changes to the system must not lead to a reduction in transparency. As stated above, transparency is one of the most valuable features of the current process in the context of a correctional system that is otherwise largely closed to independent scrutiny. 

  1. Parties with an interest in the death, including families, individuals and organizations, should have the ability to request an individual inquest.

The current proposal states that families will have the opportunity to participate in the review process and be able to still request an individual inquest into the death of their loved one, if desired. [26] The OHRC strongly supports these aspects of the proposal. 

In addition to family members, other parties, such as lawyers and stakeholder organizations, should be able to request an individual inquest. This is important as there may be people who die in correctional institutions without family members positioned to request an inquest, and because other parties may also be well placed to identify when an inquest would be in the public interest.

The option to request an individual inquest should apply to both natural and non-natural deaths in corrections.

It is currently unclear whether timelines will be imposed with respect to requests for inquests. The proposal indicates that the approach will be modelled on the current Construction Death Review process, which permits individual inquests when requested by family or a personal representative of a worker before, or within one year after, the release of the annual report.[27] Any new system for annual reviews of corrections deaths should permit requests for individual inquests along similar timelines.

 

  1. [1]Julie Ireton & Valerie Ouellet. “Ontario jails set to hit overcrowding record as bail reform looms, data shows,” CBC News (8 December, 2025), online: https://www.cbc.ca/news/canada/ontario-jails-overcrowding-data-9.7003336#full-data.
  2. ^  Human Rights Code, RSO 1990, c H.19.
  3. ^ Ibid at s 29.
  4. ^ For example, the OHRC intervened in the Coroner’s Inquest into the Death of Soleiman Faqiri who died in a segregation cell at an Ontario jail. As part of its 57 recommendations the Coroner’s Inquest jury accepted the OHRC's proposed recommendations which included strengthening access to mental health care, keeping prisoners with mental health issues out of segregation and increasing accountability within the provincial corrections system.
  5. ^ Ontario Regulatory Registry, “Amending the Coroners Act to Enable Annual Reviews of Non-natural Deaths in Correctional Institutions” (2025). See Amending the Coroners Act to Enable Annual Reviews of Non-natural Deaths in Correctional Institutions. | regulatoryregistry.gov.on.ca
  6. ^ Coroners Act, RSO 1990, c C.37, ss 33, 41.
  7. ^ Ibid at ss 31(1) and 31(3).
  8. ^ Ontario Regulatory Registry, supra note 5.
  9. ^ Letter from the Office of the Chief Coroner to Ontario Human Rights Commission (16 December, 2025), regarding request for feedback on proposed legislative change – Annual Reviews for Deaths in Correctional Institutions. 
  10. ^ Ibid.
  11. ^ Ontario Regulatory Registry, supra note 5.
  12. ^ Ontario Regulatory Registry, supra note 5.
  13. ^ Tracking (In)justice, Ontario Deaths in Custody on the Rise (2022) at 3, online(pdf): https://trackinginjustice.ca/wp-content/uploads/Ontario-Deaths-in-Custody-on-the-Rise-2022-8.pdf;  Letter from the Canadian Civil Liberties Association to the Solicitor General of Ontario, (19 December, 2022) regarding Deaths in Provincial Prisons at 4, online(pdf): https://ccla.org/wp-content/uploads/2022/12/2022-12-19-Letter-to-ON-SolGen-Deaths-in-Custody-Final.pdf.
  14. ^ Ontario Chief Coroner’s Expert Panel on Deaths in Provincial Custody, An Obligation to Prevent: Report from the Ontario Chief Coroner’s Expert Panel on Deaths in Custody (Toronto: Office of the Chief Coroner, 2023) at 1, online(pdf): https://files.ontario.ca/solgen-csdr-en-2023-05-05.pdf.
  15. ^ Ibid at 1; Independent Review of Ontario Corrections, Corrections in Ontario: Directions for Reform (Toronto: Queen’s Printer for Ontario, 2017) at 62, online(pdf): https://files.ontario.ca/solgen-corrections_in_ontario_directions_for_reform.pdf.
  16. ^ Coroners Act, RSO 1990, c C.37, in force until June 4, 2009, as amended by An Act to Amend the Coroners Act, SO, 2009, ch.15, s.6(4).
  17. ^ Office of the Chief Coroner and Ontario Forensic Pathology Service, Definitions and Guidelines for Classification of Manner of Death (Toronto: OCC & OFPS, 2020) at 7, online (pdf): https://inquests-ca-resources.s3.amazonaws.com/Documents/CAN-ONOCC/2020/Definitions-for-Manner-of-Death-Ontario-2020/Definitions-for-Manner-of-Death-Ontario-2020.pdf; Tracking (In)justice, supra note 13 at 7.
  18. ^ Tracking (In)justice, supra note 13 at 7; Independent Review of Ontario Corrections, supra note 15 at 62; Ontario Chief Coroner’s Expert Panel on Deaths in Provincial Custody, supra note 14 at 14.
  19. ^ Tracking (In)justice, supra note 13 at 7; Ontario Chief Coroner’s Expert Panel on Deaths in Provincial Custody, supra note 14 at 19.
  20. ^ Prison Health Research Program, Inequitable incarceration in Ontario (12 June, 2025), online(pdf): https://fammed.mcmaster.ca/app/uploads/2025/06/Incarceration-report-June-12-2025.pdf. 
  21. ^ The OCC should ensure that data collection practices are consistent with the OHRC’s policy on collecting human rights-based data. See: Ontario Human Rights Commission, Count me in! Collecting Human Rights-Based Data (2009) online: https://www3.ohrc.on.ca/en/count-me-collecting-human-rights-based-data. 
  22. ^ Correctional Service of Canada and the Office of the Correctional Investigator (Ottawa: CSC & OCI, 2025) online: https://www.canada.ca/en/correctional-service/corporate/csc-office-correctional-investigator.html. 
  23. ^ Independent Review of Ontario Corrections, supra note 15 at 83; Canadian Civil Liberties Association supra note 13 at 4; Tracking (In)justice, supra note 13 at 12.
  24. ^ Ombudsman of Ontario, Out of Oversight, Out of Mind (Toronto: Office of the Ombudsman of Ontario, 2017) at 43, online(pdf): https://www.ombudsman.on.ca/sites/default/files/Media/ombudsman/ombudsman/resources/Reports-on-Investigations/Out_of_Oversight-with_appendices-EN-accessible.pdf; Independent Review of Ontario Corrections, supra note 15; Ontario, Justice David P. Cole, Final Report of the Independent Reviewer on the Ontario Ministry of the Solicitor General’s Compliance with the 2013 Jahn Settlement Agreement (Toronto: Ministry of the Solicitor General, 2020), online: https://www.ontario.ca/page/independent-reviewers-final-report-jahn-settlement-agreement
  25. ^ Independent Review of Ontario Corrections, supra note 15 at 83; Canadian Civil Liberties Association, supra note 13 at 4; Tracking (In)justice, supra note 13 at 12. 
  26. ^ Ontario Regulatory Registry, supra note 5.
  27. ^ Coroner’s Inquests, online: Ontario, Ministry of the Solicitor General, https://www.ontario.ca/page/coroners-inquests.