Open Data

Responses to public fatality inquiry recommendations


This dataset serves as a public tracking system for responses to recommendations made by judges as a result of a public fatality inquiry. For each inquiry, the tracking system records the name of the deceased, the cause and manner of death, the recommendations made by the judge to prevent similar deaths, the persons and organizations who were asked to respond to the recommendations, and their responses, if any.


June 14, 2024

accidental deaths children in care correctional institutions death in custody health care facilities police services public fatality inquiries workplace safety

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Responses to public fatality inquiry recommendations

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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; a person dies in the custody of a peace officer; a person dies from the use of force by an on-duty peace officer; a 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; a child dies under the province's guardianship or in its custody; a person dies accidentally from something that’s preventable, especially alcohol and drug use; a 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, to protect the public, or to clarify the circumstances surrounding a case. The fatality inquiry happens after the police and Office of the Chief Medical Examiner 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. After an inquiry is complete, the presiding judge provides the Minister with a written report that identifies the deceased and outlines the date, time, place and circumstances of death. The report may also recommend how to prevent similar incidents, but it cannot make any findings of legal responsibility.


No licence


Contact Name

Fatality Inquiry Coordinator

Contact Other

Phone 780-422-4077