Coroner Crossfire

[Editor's note: Read the news story that relates to this document here.

In November a group led by Dr. Richard Crossland calling itself the Committee for Competent Death Reviews submitted to Solicitor General John Les a five page letter critical of changes to the BC Coroners Service. Les rejected their concerns by annotating their letter with his points of rebuttal. His document is published here. In it, the original contents of the Crossland letter are in bold face, and the responses from Les are in regular face type.]

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CONCERNS REGARDING THE BC CORONERS SERVICE

1. Incomplete Investigations of Death Child deaths not examined Medical Investigation Unit closed Suicide analysis discontinued Radical reduction in autopsies Guessing cause of death Results: Inaccurate statistics Loss of credibility - public, doctors, police

2. Incomplete Inquiry Reports Restricted in length and content Virtually no recommendations accepted Long delay to produce

3. Absence of inquests In spite of public request and need Only those required by the act Loss of public confidence

4. Morale and Retention of Experienced Coroners No doctors - conflict of interest No mayors - " " "

5. Financial Portable computerized equipment > 800,00.00 Equipment Autopsies

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December 6, 2005

Dr. Robert Crossland 160 Mansell Road Salt Spring Island, B.C. V8K 1P9

Dear Dr. Crossland:

Further to your correspondence received on November 28, 2005, I have not been able to find any evidence that the Coroners Service acted in any way inappropriately, or put anyone at risk, as a result of operational decisions made by Chief Coroner Terry Smith.

After a thorough review of your comments, I must point out that many of the concerns you have raised about the Coroners Service reflect your opinion of operational decisions made by the Chief Coroner. Although I recognize that you may not agree with these decisions, they were made within Mr. Smith's authority as head of the Coroners Service. I have full confidence in his abilities and I continue to support the work he is doing to further professionalize the BC Coroners Service.

It would be inappropriate for me to comment on specific cases however; there are a number of issues you raise that I will respond to explicitly. To that end, following is a detailed response to the points addressed in your letter.

Competence

1. Since 2001, changes to the demographics of the BCCS Regions resulted in early retirement, demotion and/or resignation of several senior and highly skilled BCCS members.

There have been planned retirements of senior managers, and several managers took advantage of early retirements. Others have been offered transfers to management positions within the BCCS to take advantage of their skill sets in specific areas.

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2. Regional Coroners were appointed or hired with less experience and/or seniority then displaced Regional Coroners. One Regional Coroner was hired despite previous documented competency concerns (Island Regions).

Retirees in any agency or company are generally succeeded by employees with less service or experience. This is a normal succession pattern. The Coroners Service has been developing new competencies related to Regional Coroner duties. Based on a set of criteria, which reflect increased responsibilities, individuals were identified within existing human resources that met the criteria. These individuals are talented and energetic coroners with the basic skills necessary to operate within this environment. All of this work has been accomplished in consultation with senior staff members and the assistance of Human Resources.

3. Trained and appointed Coroners relocating to other Regions were not automatically considered for vacant Coroners positions. Despite competent, respectable BCCS employment histories, these Community Coroners were required to apply and reapply for positions as external candidates. More often that not, individuals with no prior experience as a Coroner were hired.

The Coroners Office opens competitions to all applicants to ensure a fair and equitable process. All things being equal, a community Coroner who applies for a position in another area of the province will generally have a competitive advantage in terms of his or her experience and knowledge. In the past, it was automatically assured that wherever Coroners relocated, they would automatically be haired as a Coroner, regardless of whether additional Coroners were needed at that location.

4. In March 2003, the Behavioural Investigators, who assisted the Coroners with deaths relating to psychological or social issues, were deemed no longer necessary. Although some valid concerns had been identified with respect to Behavioural reports, the investigators were not advised and they were summarily dismissed without warning and without opportunity to address concerns. The Manager of Special Investigations did not support this decision.

The results of the evaluation of this service concluded that it did not relate to, or further, the mandate of the Coroners Service. The decision to conclude the Behavioural Program was an operational decision based on this evaluation.

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5. In August 2003, information was circulated that the Manager of Special Investigations has resigned. In fact, just prior to the release of this information the Manager advised the Medical Investigators that she would not be leaving the BCCS. In September, the investigators were advised that the Manager was on sick leave. The Manager did not return to this position and is not pursuing a wrongful dismissal lawsuit.

The information relates to an outstanding civil suit and therefore cannot be the subject of further comment. Any information circulated originated with the employee to who it referred.

6. Between September 2003 and January 2004, a review of the Medical Investigative Unit was undertaken. Medical Investigators were not invited to participate in the review and the details of the review were not revealed. At that time, nine Registered Nurses provided Investigative Services. Contracts were renewed annually. Recurring contracts were issued for up to eighteen years. Requests for status as an employee were denied.

The decision to revise the delivery of Medical Investigations was an operational decision made by the Chief Coroner, following a review of the existing program. The pervious investigators were not appointed, nor trained as coroners - often they worked part-time. This resulted in a great deal of "slippage" between the information collected, and the information contained in the Judgments of Inquiry.

Contracted medical investigators were replaced by a Medical Review Unit, staffed by two 'full time equivalent' employees, who are both Coroners and Registered Nurses. These two full-time investigators have practical experience and training as coroners, and each has the flexibility to assist coroners directly, or to assume jurisdiction as the Coroner and complete the case. This has greatly streamlined the process and eliminated the sometimes awkward interface between investigators and Coroners.

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7. In January 2004, the Medical Investigators were notified via telephone and subsequent letter that no contracts would be renewed at the end of the fiscal year in March.

Medical Investigators were assigned blocks of hours each year, and they received a contract covering those hours. With the re-organization of the unit, these contracts were no longer required. Each of the investigators was informed personally by telephone by the Deputy Chief Coroner, and a follow-up letter was sent.

8. A solitary Medical Investigative/Coroner position was soon posted by BCCS Headquarters. The successful applicant was the most junior of the contracted Investigators and was under informal re-evaluation by the Manager.

The position of Coroner, Medical Review Unit was posted with the Public Service Agency, with a closing date of March 31, 2004. The successful candidate competed for the position and demonstrated proficiency in all established qualifications. The successful individual in this instance undertook a full basic training course as a Coroner, and worked as a front-line Coroner in our Fraser Region for a number of months in preparation for assuming the position.

9. Recently, a second medical (nurse) Coroner has been assigned to assist with medical investigations and four individuals have been hired or assigned to the Child Death Review Team.

There are currently two Coroners in the Medical Review Unit, and two Coroners in the Child Death Review Unit.

10. BCCS has always had the mandate and authority to investigate reportable child deaths. The current review will hopefully determine whether the investigations were conducted appropriately.

Mr. Ted Hughes is currently examining the Child Death Review Process.

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11. In March 2005, the Assistant Deputy Chief Coroner advised that physicians would no longer be considered for Community Coroner positions due to "perceived conflict of interest". Many jurisdictions in North America utilize physicians as Coroners within a Medical Examiners type of system. The BCCS decision appear illogical, considering the lack of medical expertise with the service, as well as insulting and unfair to the physicians who have been willing to act as Community Coroners. Apparently, there is no perceived conflict of interest to appoint practicing journalists (as in Victoria), ex-policemen (who may be investigating their previous employer) and health care facility administrators as Community Coroners.

The ability of a Coroner or Coroner's agent to investigate deaths impartially and objectively is critical. Physicians employed by a Health Authority or affiliated with the local hospital, cannot work as community Coroners within the same region. As a significant portion of reported deaths occur in hospital, having a community Coroner investigate the agency for which they work, or are affiliated with, is deemed a conflict of interest.

This is consistent with the Conflict of Interest provisions of the BC Public Service Agency Standards of Conduct for Public Service Employees. The Coroners Service employs physicians as community Coroners where no conflict of interest exists or may be perceived.

This policy was grandfathered however, to allow for existing employees of the Coroners Service to continue in their positions. The Coroners Service currently employs a retired police officer who has done police background checks on occasion and acts as a Coroner. The Service also employs a nurse who is employed in a hospital. Should the possibility of a conflict of interest occur with respect to an investigation, the investigation is reassigned.

12. A Vancouver Island Health Authority mental health nurse was hired as a Community Coroner. On two occasions, she asked the Regional Coroner if there were any conflict of interest and was reassured that there were no concerns. Within days of starting work, she was "de-hired" for conflict of interest issues.

If it is determined that a Coroner's agent is also employed in a position which conflicts with the independent role of the Coroner, the agent must resign one of the positions. As

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noted above, this is to ensure the impartial objective nature of the Coroner's role and is consistent with the Standards of Conduct for Public Service Employees. The individual involved was offered a position, and then came forward with the fact that she had another job which could result in a perception of a conflict of interest. The individual was given a choice to accept the job as Coroner's agent, with the caveat that she would be required to leave her other employment - that individual chose to decline the position with the Coroner's Service.

13. BCCS no longer permits reappointment of Coroners over 65 years of age. This is contrary to the Coroners Act.

Section 1 of the Coroners Act states that "a Coroner ceases to hold office on reaching 65 years of age, but the Lieutenant Governor in Council may extend the coroner's term for any period not beyond the date of the Coroner's 70th birthday". Consistent with accepted practice for BC public service employees, the Coroners Service assumes retirement at age 65. Depending on operational needs, the Chief Coroner has the authority to request an extension of a Coroner's appointment for a period not beyond the Coroner's 70th birthday.

There is currently discussion within government around the possibility of abolishing mandatory retirement. Approximately two months ago the BCCS began supporting one year extensions based on satisfactory service, until such time as government has a definitive resolution to the issue.

14. Several experienced Coroners have left the service due to frustration and concerns relating to management and leadership. Some of the positions have not been posted or filled. As a result, Coroners in isolated areas are forced to cover larger areas. Scene attendance at remote or distant sites of sudden deaths is often delayed or not possible.

Resignations within the Coroners Service occur for a variety of reasons. Though the Chief Coroner has never received notice of a resignation due to dissatisfaction with direction or policy, it is acknowledged that there is not always agreement by all Coroners with respect to all management decisions made. The Coroners Service has been going through a period of significant change over the last four years, with the goal of increasing the quality of investigations and reports.

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Areas of coverage within the province are assigned to ensure Coroners maintain sufficient case load so as to remain current with policy and practice. Though remote sites may not warrant regular Coroner service, a Coroner is always available to attend if necessary.

15. Detailed medical investigations are rarely undertaken in the event of a sudden and unexpected deaths of hospitalized patients. Senior management advised that hospital death investigation is the responsibility of the facility or appropriate professional organization. Hospital Quality Assurance and Death Review information is often protected under the Evidence Act and not releasable to the public. Professional organizations would not initiate a review unless advised of specific concerns. BCCS suggests that the responsibility to report concerns lies with health care personal or family of the deceased. Without an independent, objective review, many concerns will be missed, not reported or not investigated. The deceased may not have any family members or the family may lack the knowledge needed to initiate a review. Historically, the Coroner has always acted on behalf of the deceased.

The Coroner continues to act on behalf of the deceased. Furthermore, the Coroners Service is working to ensure its abilities in this area are better than ever before, and will be hiring a physician full-time. In the meantime, the Service has a physician and former Coroner on contract to assist the Medical Investigation Unit in the final evaluation of these types of cases. I understand that this issue relates to pervious problems with arose when Medical Investigators identified unsupported recommendations to health care facilities or physicians, which turned out to be incorrect.

Coroners investigate deaths that occur in and out of hospital. I was provided with the minutes of the May 10th and 11th, 2005 Regional Coroners' meeting, which state: "It was agreed that issues related to the possibility of missed diagnosis or missed opportunity for treatment fall within the BCCS mandate". As well, BCCS policy states: "The Coroner must investigate In Hospital deaths that occur as a result of a natural and preventable disease if the admission was precipitated by an unnatural event". Coroners will also immediately respond if a hospital equipment malfunction or a misadventure occurs.

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Since October 2004, the Medical Review Unit has undertaken 33 detailed medical investigations, 25 of which have been completed, and assisted with close to 100 investigations undertaken by other Coroners. As noted above, jurisdiction has been transferred to the Medical Review Unit Coroners in these types of cases, resulting in much more efficient and thorough investigations than was possible with previous contracted workers.

16. Following a successful complaint against the BCCS, Community Coroners were considered employees under the umbrella of the Employment Standards Act effective June 1, 2003. Despite this ruling, Community Coroners cannot apply for government positions posted internally.

As per the advice of the Public Service Agency, "as and when required" employees such as Community Coroners are not considered "in service" employees, and therefore cannot apply for "in service" postings.

In the first three years of the Chief Coroner's tenure, he has dealt with a significant number of outstanding human resource issues and has overseen the completion of a Human Resource Management Manual ensuring consistency and fairness of practice.

Accountability

1. In April 2001, the Victoria Regional Coroners Office was amalgamated with the Nanaimo Regional Office as the Island Regional Office, located in Nanaimo. Coroners, law enforcement personnel and service providers and requests for additional information were denied. Within 18 months the Island Region Office was relocated back to Victoria.

The office of the Chief Coroner has not received any documented concerns as a result of the Victoria and Nanaimo Regional office amalgamations. Following a review of the management structure and office location in July 2003, an operational decision was made to relocate the Regional Office to Victoria.

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2. Qualifications required for the positions of Regional Coroner and other senior positions within the BCCS were changed several times within one year. Applications were sometimes restricted to BCCS employees, open to outside applications or posted for all government employees, without consistency. These changes restricted applications for some positions and the question arose whether some of the applications were customized for a specific applicant.

The time frame or positions referred to in this point are unclear. When a management position becomes vacant within the BCCS, historical practice is that managers of an equivalent level are advised of the vacancy and expressions of interest are invited. Those interested then undergo a "suitability interview" before the successful candidate is determined. Qualifications for the role of Regional Coroner were amended in May 2003 due to concerns identified as a result of a Regional Coroner competition in January 2003.

All competitors for Regional Coroner within the past five years have been "Out of Service" competitors. The position of Assistant Deputy Chief Coroner was created in November 2002. Due to the qualifications identified, this competition was open only to BCCS employees. The successful candidate was identified through a panel process that included a representative of the Public Service Agency.

Currently, the BCCS has initiated a program of management development to promote from within the BCCS.

3. Current BCCS practice dictates that when a death is not an obvious homicide, accident or suicide, even when the cause is not clear, the death is considered natural and a post mortem examination is rarely authorized. Coroners have been advised to document heart disease or cerebral-vascular disease as the cause of death or to waive the case to the physician. Physicians have been advised and directed by Coroners to complete the medical certificate of death when the most logical cause of death, based on the medical history. According to a 2002 internal BCCS memo, this practice was adopted to decrease the number of autopsies. Physicians have raised concerns that the death certificate is suppose to indicate an accurate cause of death and sometimes this is not possible without an autopsy.

This is false. The BCCS has developed a set of policies aimed at assisting Coroners in deciding when an autopsy is warranted. Post-mortem examinations are routinely authorized by the Coroner in deaths other than obvious homicides, accidents or suicides.

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With respect to investigating Natural Disease Deaths, BCCS Policy as of January 2005 requires that a Coroner must be satisfied of the following before a physician may sign a Medical Certification of Death:

(a) the physician or locum has attended to the deceased or completed a chart review.

(b) The cause of death is "natural)

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(c) The scene of death is consistent with a natural event; and

(d) There are no family or other concerns about the death.

Coroners must contact next of kin to corroborate the circumstances in any natural disease death. If there is no attending physician, or the attending physician is unwilling to certify the medical cause of death, the Coroner will take jurisdiction, and may certify the cause of death without an autopsy only after evaluation of criteria mandated by policy

The 2002policy referred to in this item is no longer in effect. Revised policy was released in February 2004 and is discussed in item #4 below.

Issues have arisen when physicians want a coroner to conduct an autopsy in order to confirm an ante-mortem diagnosis. Sometimes in completing the BCCS mandate Coroners may satisfy this demand and at other times they may not. There are other alternatives including in-hospital autopsies that may satisfy a physician's mandate

4. The practice of "guessing" the cause of death renders statistical death information inaccurate. Valuable information relating to trends of diseases, infection and/or hereditary information which may affect prevention of future deaths is not routinely pursued. Health resource allocation may be inappropriate if based on current statistics.

Any suggestion that Coroners are guessing or have been directed to instruct physicians to guess the cause of death is false.

Legislation and policy dictate the Coroner's mandate and investigative responsibilities with respect to determining the circumstances of death within the province, Coroners do not guess at a cause of death, rather, they determine the cause of death following

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Examination of the body, scene, circumstances and history. Many times the cause of death is clear from examination of the body and scene. In other cases, the cause of death can be reasonably determined after additional review of medical records and consultation with medical personal and the deceased's family members. If the Coroner is satisfied that the cause of death has been reasonably established, and there are no unresolved concerns, an autopsy is not conducted.

Investigative Policy effective February 2004 states:

"A Coroner, prior to proceeding to investigation of a case without autopsy (Coroners Case No Autopsy), should be able to identify a reasonable presumptive cause of death, based on an evaluation of all the relevant associated background and circumstances including but not necessarily restricted to the following

(a) whether the medical history, scene, investigation and examination of the body are consistent with cause of death;

(b) whether the circumstances are consistent with the cause of death;

(c) whether there are any issues of concern with family or agencies involved"

Though Coroners Service statistics are utilized for research purposes, the Coroners Service investigates to satisfy the mandates of the Coroners Act. Once the Coroner has established the cause of death according to the criteria above, authorization to conduct an autopsy to establish clinical information is not an appropriate function of the Coroner's office.

I would encourage any physician who has concerns to direct these to the relevant community Coroner, and if the concerns are not satisfactory resolved, to the Office of the Chief Coroner.

5. According to concerns published by a Vancouver Island physician, a Community Coroner refused to authorize an autopsy and insisted that the physician classify the death as natural, even though the cause of death was unclear.

As discussed in item #3 above, there are clearly established criteria the Coroner must satisfy before waiving certification of a natural death to a physician. A physician may only certify a natural death. All other deaths must be certified by the Coroner. This particular physician has not brought any concerns to the attention of the Office of the Chief Coroner.

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6. The College of Physicians and Surgeons of BC raised similar concerns regarding the refusal by the BCCS to authorize autopsies and pressure physicians to complete Medical Certificates of Death despite the physician's inability to explain the circumstances of death.

The Chief Coroner has a well-established relationship with the College of Physicians and Surgeons, and discusses issues of mutual concern on a regular basis. There have been a number of concerns raised by the College. One relates to the inappropriate unsupported recommendations of previous medical investigations. The general topic of autopsies has also been discussed with the College liaison, and with the Quality of Care Committee of the College.

In one instance, the autopsy policy was extended beyond a reasonable point and that has been acknowledged by the College. The concern the College has raised revolves largely around the need for a specific cause of death in order to respond to complaints from family members relating to the actions of a physician. The BCCS continues to work with the College on these and other issues to the mutual agreement of both the College and the Coroners Service.

7. Despite requests for an autopsy from physicians and/or family members, when authorization is denied by the BCCS, physicians are advised to request hospital authorized autopsies and family members are told that they can request an autopsy if they with to incur the cost. Following completion of these autopsies, the BCCS may seize the results and utilize the information for completion of their report(s).

Investigation Services Policy regarding the use of clinical (hospital) autopsy reports states:

1. In those cases where a Coroner has not assumed jurisdiction of a case, clinical autopsy results should not be accessed.

2. In those cases where the Coroner has jurisdiction but has not ordered an autopsy, or where a Coroner has initially waived jurisdiction of a case but then assumes jurisdiction within a few days of death, the Coroner should issue a Form B or access the clinical autopsy report. This will allow for the appropriate payment to be made for that autopsy.

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8. The solidarity position of Medical Investigator/Coroner, posted in 2003, was deemed to be a senior management position. According to the Assistant Deputy Chief Coroner, the position required consistent presence at the head office in Burnaby. This relocation requirement limited the ability of some senior medical investigators to apply for this position. The Assistant Deputy Chief Coroner now resides in Victoria, with an office maintained in both Victoria and head office in Burnaby. This double standard does not support accountability within the BCCS.

The position of Medical Investigator was posted in 2003. At that time there was no wireless network to assist in remote job locations. It was determined that there was a need for regular and consistent interaction with staff from the Office of the Chief Coroner, With the impending implementation of TOSCA (the new database) and the recent roll-out of wireless laptops, it is now possible to contemplate and accommodate alternative work arrangements.

The position of Assistant Deputy Chief Coroner commenced April 1st, 2003 as a position situated at the Office of the Chief Coroner in Burnaby. Due to a personal situation which required the incumbent to reside in Victoria, and in consideration of the best interests of both the incumbent and the agency, the Chief Coroner approved an arrangement allowing the employee to work at office locations in Victoria and Burnaby. It was determined that the individual was a valued and committed employee whose skill set would be impossible to replace. This - combined with a small experience base within the BCCS - prompted senior management to experiment with this remote job site initiative. The effectiveness of the arrangement will be evaluated at the end of the year.

9. In an effort to improve quality of Coroners reports, a standard format was adopted. Little flexibility is permitted with respect to working of the reports and considerable editing is routine. Information, which the Coroner believes is important for family members and the general public, may be changed or deleted and the Coroner is expected to comply. The review process involves several levels within the BCCS, with the final reports not always reflecting the facts or concerns and recommendations identified by the Coroner. This process also significantly delays the release of the final report. Media have expressed frustration on numerous occasions about the increasing delays with the release of information from the BCCS.

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There has been significant delay in the release of reports. Much of this was due to such things as lack of technology, secure e-mails, and the ability to deliver timely supervision to community coroners, as well as cumbersome processes such as the previous method of completing medical investigations. The Coroners Service has produced a manual to assist Coroners in the completion of Judgments, and now provides improved report writing training. Additionally, the BCCS is beginning to conduct quality assurance activities which provide feedback to supervisors and translate into directed training activities.

The completion of TOSCA, the wireless network, the BCCS Intranet site, the Judgment writing guide, improved training and the improved ability to access supervisors in real time are serving to gradually eliminate these delays. The BCCS continues to work with all staff to assist in time management, file maintenance and investigational planning.

10. Issues of public safety or concern are rarely dealt with via an Inquest. Historically, the inquest process reassured the public that the BCCS complied with the mandate to provide open and independent death reviews for the citizens of BC. Although the Coroners Judgment of Inquiry Report is meant to reflect the fact surrounding a death, the information is only available to the general public upon request, when the name of the deceased is known and provided. Recently, only cases mandated within the Coroners Act have been called to inquest.

The Coroners Service is providing upgraded training with respect to presiding at Inquest, and not limits such activities to Coroners who have some experience. The BCCS is currently in the process of hiring a staff lawyer to assist with Inquests and a variety of other legal issues. Additionally, the BCCS is looking at alternative means of exploring public safety issues, including the ongoing surveillance and monitoring of trends in common causes of death. This monitoring will be translated into Subject Specific Reviews, in which subject-experts will participate, resulting in public reports and recommendations relating to prevention.

11. The last annual report from the BCCS was released in 2002.

The Coroners Service produces an Annual Report which summarizes the total number of deaths reported for each year, the types of deaths and other relevant statistics. While the Coroners Service recognizes that it is behind schedule in posting Annual Reports, there is often a delay due to the very nature of the Coroner's business.

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Final reporting of statistics is often deferred until all cases in the province have been concluded, and the causes of death finalized. This ensures that agencies relying on the information in the Annual Report are provided with finalized dates which is not likely to change. In the meantime, preliminary statistics are posted to the BC Coroners Service Internet (currently updated to 2004) so that they are available to the public. The Coroners Service also continues to respond to on-going statistical research and other information requests as required.

12. Statistics collected by the BCCS for suicide, homicide and accidental deaths do not coincide with the Bureau of Vital Statistics. No suitable explanation has been offered or found.

There has been no expression of concern from the Vital Statistics agency regarding a discrepancy between its statistics and statistics of the Office of the Chief Coroner. According to the BCCS statistician, those of the Chief Coroner's Office are more accurate as they reflect frequent updating and review as cases are closed. Those of the Vital Statistics agency may not be updated as consistently, and may sometimes be based on preliminary reporting.

The BCCS has participated in and will be a subscriber to a national Coroners/Medical Examiners Database sponsored by Health Canada. Memorandums of Understanding are currently being prepared for consideration by all provinces and territories.

Cost Containment/ Fiscal Management

1. Upon amalgamation of the Victoria and Nanaimo Regions in 2001, both Regional Coroners chose retirement and a fill time Victoria Coroner was appointed as the Island Regional Coroner. The new Regional Coroner resided in Victoria and was provided with a car and travel expenses to commute to Nanaimo. Soon after, the Regional Coroner was offered the position of Assistant Deputy Chief Coroner (ADCC) at Head Office in Burnaby. Initially, travel and accommodation expenses were provided until a formal move to Vancouver could be arranged. Moving expenses were then provided. The ADCC has recently returned to reside in Victoria, continuing in the same position. Moving expenses were again provided.

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The Chief Coroner makes compensation and reimbursement decisions with due consideration of the best interests of the incumbent and the agency. These decisions are consistent with government policy regarding travel and moving expenses. The incumbent is responsible for regular travel costs between her residence and the Office of the Chief Coroner.

2. As mentioned the Island Regional Coroners office was centered in Nanaimo in 2001 and relocated back to Victoria in 2003. Considering the overwhelming concern when the initial move was announced, the cost for this brief relocation speaks for itself.

This issue has been covered above.

3. Community Coroners have been advised to falsify their invoices/timesheets to prevent overtime pay, even if the Coroner completed tasks outside regular hours. At times, invoices for time spent working or report writing were not authorized because the Regional Coroner believed the time was excessive. Although abuse of time and suspected fraudulent billing should be dealt with, withholding payment when legitimate work has been completed is inappropriate and demeaning, if not against labour law.

It is difficult to address this one specifically as there is little detail and no evidence to support this accusation. I have no evidence that this has ever been the case in the BCCS. Regional Coroners are responsible for ensuring invoices submitted by community Coroners are consistent with direction supplied by policy. All overtime expenses must be approved by the Regional Coroner before they are incurred.

4. Golf shirts and fleece vests, complete with the BCCS logo were provided to all Coroners and service providers in 2001. These were sent as tokens of appreciation from the Chief Coroner although many individuals expressed the desire that the funds be utilized for training or other priorities.

The Chief Coroner distributed these items under the employee recognition program as an attempt to recognize the hard work and dedication of the BCCS staff working in isolated and difficult conditions. I understand that the vast majority of staff members have responded extremely favorably to this initiative. I have been assured that the minimal expense involved would not have impacted training or any other activity in a meaningful way.

5. In 2005, BCCS spent approximately one million dollars to equip 120 Community Coroners with electronic equipment. In isolated areas, the caseload is so low that the equipment is of no benefit. The yearly maintenance, expense and upgrade budget is approximately $250,000. The medical investigative budget for nine nurses was $192,000 per year before they were summarily dismissed.

I am confident that the purchase of electronic equipment was a sound operational decision by the Chief Coroner. The BCCS has reduced the number of community Coroners to 85 and has linked all of them into a province-wide technology network which - amongst many other benefits - facilitates distance training, information exchange, electronic report writing, real-time supervision, access to manuals and policy, investigative protocols, report and photograph transmission in a secure environment and consistent data collection.

6. Community Coroners have been provided with kits, which include equipment suitable for crime scene investigators, not Coroners. Community Coroners were not consulted about equipment needs. Basic equipment, such as boots, gloves and raingear was not provided.

The equipment provided was thoroughly researched by the Deputy Chief Coroner, and the kit was developed by an experienced company who also produced the kits issued to B.C. Ambulance staff. Coroners in the field were also consulted. In addition to the "scene kit", Coroners now receive identifiable clothing consisting of a cold weather coat with zip-in lining, a light nylon shell, overalls, hardhat, and ball cap. This is not a complete "kit"; however, it is a significant improvement upon what existed in prior years.

In conclusion, I have found nothing that dissuades me from my confidence in the Coroners Service or the Chief Coroner. Pursuant to his authority as Chief Coroner, Mr. Smith has made operational decisions based on a clear direction set forth when he assumed his position. Some of the issues you have discussed, such as closing the Behavioural Program or moving from a Medical Investigation Unit to a Medical Review Unit, are decisions which are made within the sole discretion of the Chief Coroner, and it would be inappropriate for me to interfere in such decisions.

I am confident in saying the Coroners Service has seen significant improvements over the last four years and I see no basis whatsoever on which to perform an audit of this organization. The BCCS is strong, committed and cohesive team, and it moving forward with a documented vision for the future. I will continue to work with the Chief Coroner to ensure that the appropriate funding is in place for the continued success of the BC Coroners Service.

Thank you for taking the time to write with your concerns.

Yours Truly,

John Les

Solicitor General