Accessing information: Autopsies, inquests, and boards of inquiry

Obtaining an autopsy report is one way to access information about a death. In Canada, families generally have access to autopsy reports. Generally, the adult next of kin can request the report from the Chief Medical Examiner's office after an investigation. However, the availability and process can vary, and there might be situations where access is restricted or requires a formal request. 

I finally requested the autopsy report, which told me that it was seconds before he lost consciousness, so he didn’t suffer. That was really a comfort because the fear that he was scared and suffering was hurting me for a long time - my mind couldn’t let it go. - Family Member

If you have access to the autopsy report, it is important to be well prepared for the process of reviewing it. It can be a difficult experience. It may not provide the answers you were hoping for, and it may leave you with new questions.

• Do you want to read the report in one sitting or a bit at a time?
• Would you like to have someone read it to you?
• Would you like someone to preview the information before you read it? Let them know if you want them to tell you how difficult or upsetting they found the report, or think you may.
• Would you like to have someone review the autopsy with you at your own pace? This could be a friend, family member, a trusted health care provider or a grief counsellor.

• Have someone check in with you on the day you read the report.
• Consider what may help you process what you read, such as journaling or counselling, or being with a supportive friend or family member.
• Consider a self-care activity you can plan afterwards, like taking a walk outside, being with someone.

You may or may not want to attend an inquiry or inquest. This process can be very helpful in your grief but might also be extremely challenging. Consider finding someone who can support you and explain the process. This might be a friend, or a health care, or mental health professional who can accompany you throughout the inquest.

It lasted two weeks. On the one hand, the inquest was the hardest thing to experience. You don’t want to hear about how someone mistreated your son and how he was let down by those around him. You also don’t want to hear negative things about how your son behaved or how he handled things.

But in the end, I was able to look at all that information and realize that there was nothing that I missed, nothing that I could have done differently. That was hugely healing because I realized that I wasn’t responsible - not that I ever was responsible, but I felt so much guilt and uncertainty about that. At the end of the day, it was the best thing for me and my grief. - Family Member

The board of inquiry or inquest might provide you with a better understanding of what happened. You may also find that it changes your grief in ways you didn’t expect.

The inquest didn’t just help with my guilt - it also helped with my anger. Going into the inquest I wasn’t about to forgive anybody. Then, all of a sudden, watching this man speak about what happened, I found myself forgiving him and realizing that it was the whole system’s fault. The forgiveness was unexpected because I was focused on one thing for three years: anger. Then in an hour, it’s taken away from you. I felt relief, but also emptiness and sadness. But in many ways that emptiness and sadness made me feel like a normal person again, because anger is really hard to carry, way harder than emptiness. - Family Member

Try to prepare yourself for the possibility that you won’t agree with the outcome of the inquest, which may intensify your grief.

The board of inquiry into his death was another slap in the face because they came back to say that they didn’t do anything wrong. So, my question is, "What changes have you made to make this better for these soldiers who are suffering?" As far as I know, nothing. Almost four years later, nothing. That’s really hard for me. - Family Member

The inquest might give you a new path forward and a way of honouring the person who died.

The inquest found that there were several potential improvements that could be made in handling cases where someone is suicidal. At that point, I realized that, as much as I want to change how things happened, I can’t. But now, I can advocate on his behalf to save lives in the future. That’s his legacy. And my purpose moving forward? To save lives. We’re trying to make a difference in the world on his behalf by advocating for these recommendations to be implemented. So, the inquest redirected me from anger to a sense of purpose. - Family Member

You may be caught off guard by intense waves of grief at unexpected moments, as the reality of the death starts to sink in. This can leave you feeling off-balance, fragile, and emotionally drained.