The Inquest Coroner is responsible for the conduct of the inquest which may initially include reviewing the evidence, selecting witnesses and ruling on requests for standing. The Inquest Coroner ensures the process is in keeping with the rules of natural justice. He/she may rule on procedure and evidence.

In Nunavut, an inquest must be held in all cases where a person dies while held in custody, for example, in a jail, under Mental Health Act or correctional facility. These inquests are mandatory. The only time that an inquest would not be held in these cases is where the person died from natural causes, i.e., natural diseases, and the death is not preventable.

In other instances of sudden, unexpected or unnatural death, the Chief Coroner may decide to hold an inquest. These discretionary inquests may be held for one or more of the following reasons:

• to determine the identity of the deceased and how, when, where and by what means he or she died;

• to inform the public of the circumstances surrounding a death;

• to make dangerous practices or conditions known and make recommendations to avoid preventable deaths; or

• to educate the public about dangerous practices or conditions to avoid preventable deaths.

An inquest will not be held until all investigations and legal matters have been concluded. This may include completion of the final autopsy report, finalization of criminal charges, occupational health and safety investigation, and independent police investigation. This may take several years. Typically, inquests are held within 24 to 36 months of the death. It is important for these legal investigations and matters to be concluded before an inquest so that the outcome of those processes are not jeopardized and so the information coming out of them may be considered as part of the inquest.

Once all matters have been concluded and the Chief Coroner determines that an inquest will be held, the process of organizing the inquest begins. Some of the steps in this process include:

• Assigning an Inquest Coroner to preside at the inquest as well as Coroner’s Counsel who assists the Inquest Coroner;

• Choosing a venue for the inquest. Inquests are always conducted in a location nearest to the place of death in order to provide the best access to the appropriate community members to attend the inquest. Inquests are held in a variety of facilities including court rooms, or in town halls or community centers;

• Choosing a date for the inquest. Inquests, typically, are held over a 5 to 15 day period depending on the case;

• Arranging for a court reporter and sheriff to attend the inquest;

• Summoning individuals who may be selected as jury members for the inquest;

• Coordinating the attendance of the family representative and their support person, persons with standing, and witnesses.

The next-of-kin will be informed of the date and place of the inquest. The Coroner will decide on the witnesses to be called, however if next-of-kin have information which may be helpful at the inquest, they should communicate this to the Coroner as soon as possible.

Persons with standing may choose to be represented by Counsel or an agent. However, there is no legal requirement for persons with standing to be represented by counsel or an agent. If not represented, those with standing should be aware that Coroner’s Counsel will make every effort to ensure that their questions/concerns are addressed and that they are afforded the opportunity to question the witnesses should they choose to.

Persons with standing may review all evidence including copies of documents, reports, photographs, or other evidence admitted at an inquest. Legal representatives of those persons with standing may receive copies of the documents, reports, photographs, or other evidence with undertaking agreements and conditions. It is at the discretion of the Inquest Coroner to make decisions about which documents or exhibits are relevant as evidence in an inquest.

Usually a Coroner will explain the process before the inquest begins. Witnesses will be called in logical sequence and give evidence under oath. The Coroner will usually also give an opportunity to anyone who wants to withdraw during the evidence of the post mortem examination to do so and to return later.