Coroner’s recommendations | Answers that don’t come

The Ministry of Health and Social Services (MSSS) as well as many public organizations fail to respond to the recommendations of the Coroner’s Office within the prescribed deadlines, noted The Press.

For more than a year, i.e. the 1er November 2022, individuals, associations, ministries or organizations must confirm to the chief coroner “that they have taken note of the latter’s recommendations and inform him of the measures they intend to take to correct the situation” . A simple acknowledgment of receipt is not enough.

The Coroner’s Office had been asking for this legislative change for several years due to the laxity of certain interlocutors. For the 2022-2023 budget year, the response rate to recommendations was 42.4%.

The maximum response times set by the chief coroner in his letters are 45 days, but the MSSS, the organization most requested by the reports, has a tolerance of 90 days to position itself due to the delay accumulated during the pandemic .

The Ministry nevertheless contravened the Coroners Act on at least 11 occasions in the last year, according to our analysis of a document from the Coroner’s Office which details the follow-up of the recommendations issued on 1er April 2022 to March 31, 2023.

We have excluded from this count requests sent before 1er November 2022, when the new law was still not in force. We also ensured that the 90-day deadline specific to the MSSS has expired.

Some recommendations propose very concrete solutions to “protect human life”. A coroner asks, for example, to “ban support bars for beds (assistance bars) with a single crossbar and [de les remplacer] by support bars for beds which have at least two transverse bars”.

At the time of publication, the chief coroner had still not received acknowledgment of receipt of this recommendation sent on January 19, 2023.

Other recommendations left unanswered by the MSSS concerned reporting to the Youth Protection Department, psychological follow-ups, the identification of suicidal risks and the management of calls to emergency services.

As of March 31, 2023, the Ministry had only responded to the recommendations in 3 of the 22 files submitted to it since March April 2022, we note in the follow-up document produced by the Coroner’s Office. This report, however, covers a period of seven months during which responses were not obligatory.

“Delay” in responses

“We are in contact with the Ministry,” said Reno Bernier, chief coroner of Quebec, in a telephone interview with The Press. They are aware of this issue. »

It’s true that the response rate was not high, but they are developing a plan to catch up with the backlog. I am confident, but it is certain that there is a lot of work to be done.

Reno Bernier, chief coroner of Quebec

The Coroner’s Office, which says it has excellent relationships with public organizations, has access to a contact person at the Ministry of Health. He would nevertheless like the management organization chart to include a recommendation follow-up office similar to that established by the Ministry of Transport.

Questioned by The Press, the MSSS admits to being “delayed” in its responses. He particularly blames the accumulation of files during the management of the health crisis from 2020 to 2022. “Intensive work is underway to catch up,” explains a spokesperson by email, adding that “several responses to the coroner’s recommendations will be transmitted soon”.

The Ministry says it attaches “great importance” to the work of coroners. “When a report involves recommendations for the MSSS, these are transmitted upon receipt to the ministerial directorates concerned so that follow-up can be carried out and these recommendations can be considered in current and future work. »

Beyond formal correspondence, the MSSS specifies that it has frequent contact with the Coroner’s Office, “in particular to ensure the dissemination of information and obligations concerning the new Law.”

A widespread issue

The Ministry of Natural Resources and Forests, the Ministry of Transport, the Ministry of Municipal Affairs, the City of Montreal Police Service, the General Directorate of Public Health of Montreal, the City of Quebec, the City of Montreal and the Société de l’assurance automobile du Québec were all in violation, by their silence beyond 45 days, in at least one file dated March 31, 2023.

More ironically, even the Ministry of Public Safety, to which the Coroner’s Office reports, contravened the Coroners Act by not following up within the allotted time on recommendations made on January 19, 2023 in an overdose case.

For the 2022-2023 budget year, the Coroner’s Office made 754 recommendations in 282 files. The response rate was 42.4%, according to the independent organization’s management report. When they give signs of life, organizations agree to implement the recommendations about 9 times out of 10.

Some 80 health centers, public organizations, associations, professional orders, municipalities and private companies had not responded to at least one recommendation from the chief coroner sent from 1er April 2022 to March 31, 2023. Several were contacted after March 1er November, thus contravening the law.

“Transition year”

The chief coroner of Quebec, Reno Bernier, notes that his partners are in “a year of transition, of implementation” with regard to the new Coroners Act. However, “the situation is not [son] taste optimally.” “A response rate of 42% is not enough,” he said. I would like it to reach 75%. »

Although the Coroners Act does not provide for criminal sanctions, Mr. Bernier assures that it promotes accountability.

Every deputy minister is accountable. Each year, when the credits are studied, he must answer for his management. And there are researchers, organizations and journalists who can demand accountability.

Reno Bernier, chief coroner of Quebec

The Coroner’s Office is in the process of developing a public tool for monitoring recommendations in real time, which could increase pressure on organizations and departments and “highlight their work”.

“Recommendations are one of the most important parts of the coroner’s work, because they make it possible to change things, prevent deaths and help society evolve,” argues Mr. Bernier.

Which deaths require a coroner’s report?

A coroner “systematically intervenes when a death occurs in violent or obscure circumstances or possibly linked to negligence, or when the identity of the deceased person is not known”. Different professions, for example a doctor or a manager, have a reporting obligation in these circumstances. The Coroner’s Office must also be notified of any death that occurs in specific locations, “particularly in daycares, youth centers, foster homes, police stations, detention facilities, penitentiaries and centers rehabilitation”. Nearly 70,000 deaths occur annually in Quebec, of which some 6,000 are the subject of an investigation by a coroner. If he considers it necessary for the public interest, the chief coroner may order a public inquiry. This was the case, for example, following the seven deaths that occurred during a fire in Old Montreal on March 16. The author of a report is free to make recommendations or not.

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