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Protecting Albertans
The public fatality inquiry process
By Sarah Dafoe

Medical Examiner's Autopsy Suite
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The public fatality inquiry is integral to Alberta’s justice system. Recent government amendments made to the Fatality Inquiries Act help to strengthen and increase the efficiency of the inquiry process.
The goals of a public fatality inquiry are to increase awareness of circumstances that put lives at risk, to present the circumstances of a death to the public, and to increase confidence that authorities are doing what is necessary to protect all Albertans.
Public fatality inquires can only be held for deaths that have been investigated by the Medical Examiner’s Office.
After completing an investigation into a death, the Chief Medical Examiner forwards the case file to the Fatality Review Board. This is done in some cases because the law requires it, but in most cases because the family or an interested party to the death has requested a review or because the Chief Medical Examiner believes it would be beneficial for the board to review it.
Following the board’s review and discussion of the file, it makes a recommendation to call or not call a public fatality inquiry. The Minister of Justice must call an inquiry if the board recommends one. He may also call an inquiry without a recommendation from the board, if he believes it is appropriate.
Public fatality inquiries are held before a provincial court judge, and are intended to present the details and circumstances surrounding a death in a public forum. A Crown lawyer presents witnesses and evidence, and any party whom the judge deems to have an interest in the inquiry (most commonly the next-of-kin) may question witnesses themselves or through their legal counsel.
Once the testimony is complete, the judge prepares a written report of his or her findings. The judge cannot make any findings of legal responsibility or assign blame, but may include recommendations to prevent similar deaths from occurring in the future.
The Medical Examiner’s Office investigates about 20%-25% of all deaths that occur in Alberta. Very few of these deaths become involved in the fatality inquiry process.
However, if a prisoner dies in jail, if someone is killed by a police officer in the line of duty, or if a child dies while in the government’s care (i.e. a foster child), there will be a mandatory public fatality inquiry unless the Fatality Review Board is satisfied that the death was due entirely to natural causes, was not preventable and the public interest would not be served by an inquiry.
Amendments to the Fatality Inquiries Act allow the Fatality Review Board to use their judgment in calling for a fatality inquiry in the rare circumstance where there is no meaningful connection between the death and the fact that the deceased was in the custody, care or guardianship of the government.
The Fatality Review Board will continue to carefully review each case. Fatality inquiries will always be recommended if the board believes it would be appropriate to do so and if the board does not make such a recommendation, the Minister retains the right to call an inquiry.
An average of 23 public fatality inquiries are called
in Alberta each year.
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