Psychiatric Patient Advocate Office - Bureau de l'intervention en faveur des patients des établissements psychiatriques
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Mandatory Inquests

The Psychiatric Patient Advocate Office (PPAO) is concerned about the number of patient deaths following admission to mental health facilities, immediately following discharge or when a person is denied admission to a mental health facility. We are also concerned that in many of these cases inquests are not held, despite urging from advocates, family members and other stakeholders.

Mandatory Inquests - Ontario Human Rights Tribunal Decision - Finding of Discrimination
On May 25, 2006 the Honourable Justice Peter Cory on behalf of the Human Rights Tribunal of Ontario released its decision into the deaths of Melba Braithwaite and Thomas Illingworth and the Coroner's failure to call an inquest. Currently the Coroners Act does not require a mandatory inquest into the death of a psychiatric patient but it does require mandatory inquests when an inmate dies in the custody of the state.
        Read the Decision...  OR 
        Read News Release...

Appeal of Human Rights Tribunal's Decision
In December of 2007, the Divisional Court of the Ontario Superior Court of Justice agreed with the Attorney General of Ontario and the Office of the Chief Coroner of Ontario that the Coroners Act does not contravene the Human Rights Code.

This is a very disappointing decision. The Psychiatric Patient Advocate Office, along with others, had argued that it was discriminatory to hold mandatory inquests into the deaths of individuals being held in police detention but not those individuals who died under psychiatric detention in psychiatric facilities.

The Human Rights Commission has already sought leave to appeal the Divisional Court's decision to the Court of Appeal for Ontario, as has Renata Braithwaite. The motion for leave to appeal should be heard in March 2008.

The Court set aside the decision of the Tribunal and provided written reasons on December 18, 2007 PDF file of Court decision

Inquests that have been held, and related events, where the PPAO has been involved:


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