REGINA — Saskatchewan’s provincial auditor has said that the Coroners Service is not completing its reports or following up on coroners recommendations in a timely manner, which could be a risk to public safety.
In a report compiled by provincial auditor Tara Clemett, released on Dec. 7, it was found that the Saskatchewan Coroners Service was "not always completing and communicating coroner reports promptly.”
“This can negatively affect families waiting for coroners’ reports, and increase the likelihood that public safety remains at risk,” said a statement from the audit.
The Coroners Service holds investigations into unexplained, unnatural or unexplained deaths in the province, typically that result in both a final report and a set of recommendations developed to help avoid similar deaths in the future.
There are currently nine coroners employed under the Coroners Service to conduct these investigations, all of which were interviewed by the auditor for the report.
In the last four years, death investigations conducted by the Coroners Service have increased, now totalling about 23 per cent of all deaths in the province. In 2020, a total of 2,652 death investigations were completed by the Coroners Service.
Following policy reviewed by the auditor, Clemett found that the average expected turnaround time for a coroner's death investigation should be around three months after a person’s death.
However, the auditor found that in a sample of 30 case files reviewed, six were not completed within this expected timeframe. Four cases were determined as suicide, which take longer to investigate, and were ruled acceptable.
The other two cases showed that coroners waited more than five months after receiving final autopsy reports to provide a concluding signature and provide results to these families.
“Management indicated coroner performance issues as the reason for delays,” said the report, before noting the coroners in question were rescinded by management.
As of June 2021, the auditor also noted there were 20 investigations that have been outstanding for more than six months.
Some investigations in the hands of the Coroners Service could be delayed due to factors outside it's control, noted the report, including cases where the coroners are waiting for outside supports in the investigation or the remains of the deceased cannot be identified.
The coroner's office has also had to delay some public inquests in the past year due to pandemic safety protocols, thus postponing final reports and recommendations in those cases.
But Clemett said any kind of potential delays in conclusions to these types of investigations could cause problems for the public.
“An investigation can uncover genetic or environmental — for example, a bacterium or fungus — diseases that could affect other family members or individuals,” said the report. “Investigations also inform the public of circumstances surrounding a death, [and] bring dangerous practices or conditions to light.”
Uncertainty regarding a person’s death can also cause delays in insurance benefit delivery, and put psychological strain on families and loved ones.
The auditor’s report said that while the Coroners Service has adequately comprehensive policies and procedures established for death investigations, expected timelines for actions on the coroners checklist are not always properly communicated to employees.
Clemett also found that the service is not always following up on the recommendations it makes to agencies during investigations, in a timely manner.
During the audit period, the coroners service made 26 recommendations to 10 different agencies. Only seven of those recommendations received a response, and 16 were past the six-month timeframe for follow-up action.
Aside from these points, Clemett concluded that the Coroners Service and it's overseer, the Ministry of Justice, had “effective processes” regarding investigating unusual deaths.
The Coroners Service policies and operations show good practice, said Clemett, and only a few additional mechanisms are needed.
Clemett provided eight recommendations to the Coroners Service to improve its performance, including the creation and adherence to a structured timeline to communicate investigation results to families and loved ones.
An independent review of investigation files and reports prior to giving them to families should also be added to the process, said the report.
The auditor is also recommending the Coroners Service centrally log complaints and actions taken to resolve them, and more regular reports to senior management regarding activity and investigation results.
