Tall Poppy Interview: Dr. Barry McLellan, Chief Coroner of Ontario

By Marc Lostracco

26 Grenville Street is a large, ugly monolith with worn floors, recycled furniture and not much natural light. It’s typical of government buildings built decades ago, but despite its dismal brown tiles and threadbare carpets, it houses one of Toronto’s most interesting places: the city morgue.
Here, up to a hundred bodies temporarily reside while the Office of the Chief Coroner studies the details behind their deaths to better serve the living. The Coroners Building has been home to anything from the most newsworthy murder case to anonymous suicides, and if you meet with some strange demise in Toronto, you’ll end up here.
We sat down with Dr. Barry McLellan, the Chief Coroner of Ontario, to talk about science, disasters, and unidentified human remains.

What is the role of the Chief Coroner?
The Chief Coroner administers the Coroners Act and as Chief Coroner, I have responsibility for supervising, directing, and ensuring appropriate education of all coroners. Our system is based on a physician coroner model, which is not the most common. In Canada, only Prince Edward Island and Ontario have physician coroners.
There are different death investigation systems: you’ve got either a medical examiner system or a coroner system, with the coroner system having more involvement in advancing public safety and the medical examiner system dealing more commonly with certification of death. Across the world, most coroner systems are lay coroners. In Ontario all 350 of those investigating coroners are physicians.
How many cases do you deal with?
In the province each year, there are 80,000 deaths and 20,000 of those are investigated by our office. We do autopsies for about one out of every three of those. Out of those 6500, about 1500 to 1600 of the autopsies are done here [at the Grenville Street facility]. Many of them are done elsewhere in hospitals because of the large size of Ontario.
Out of those 20,000 death investigations, 5000 are within Toronto. In Toronto at any given time, we have about twenty investigating coroners.
Is there ever any shortage of staff? That seems like a lot of work.
In some of the smaller, more remote communities, there are obviously fewer death investigations. I would say our greatest difficulty is not in the larger centres, like Toronto or Ottawa or Hamilton. Our greater difficulty is in a smaller community where there may only be one or a small number of family doctors. We need coroners to investigate cases throughout the entire province.
Here’s an example: we’ve had two tragic, high-profile deaths in Kashechewan and we don’t have a coroner in Kashechewan. The closest coroner we have is in Moosonee, so we have to deal with some of those deaths remotely. We still investigate, but we’re giving direction to police officers and others at the scene.
What would constitute the need for investigation?
In general terms, coroners will investigate all unnatural deaths. So, anyone who dies of anything other than natural disease, a coroner will investigate, be it accident, suicide, homicide, or what we’d classify as undetermined. We also investigate all sudden and unexpected natural deaths. On top of that, there’s some specific circumstances in the Coroner’s Act: if a woman dies while pregnant or following pregnancy when the death may have been caused in part by the pregnancy. We investigate one out of every ten deaths that take place in a long-term care institution.
Being the headquarters of the Chief Coroner of Ontario, what happens in this particular building?
First, we have an administrative role. This is where all our records are kept, where we have our quality assurance and improvement operation and our educational courses originate from here. This also houses the provincial morgue. This is the largest facility we have for body storage and it’s the largest facility for conducting autopsies, so this is where the largest number of autopsies are done and also the most complex autopsies. If we have a homicide anywhere in the greater Toronto area, it will be done here. If we have a very complicated case of found skeletal remains anywhere in the province, it will be brought here.
How many bodies do you store in this building?
We have storage for about 100 bodies. We also have skeletal remains where we don’t need to use the body storage area with the separate doors and refrigeration, and we have a large autopsy area where we’re able, if necessary, to do three autopsies at a time. It’s unusual for us to do more than two at a time. Most hospitals would have storage for maybe ten, sometimes upwards of fifteen bodies. If ever there was a mass fatality event; if ever we have a body that can’t be identified and needs to be stored, this is the provincial resource.
In a case when a person is unidentified and no foul play is suspected, how long do you retain the body?
In a case where we have an intact body and it’s not a criminally suspicious case, we usually hold that body for about a year, when it is ultimately released for a municipal burial. We try and wait as long as possible. We don’t want to be in a situation where somebody comes forward a few months later and we’ve already buried their loved one. On the other hand, for practical reasons, we can’t keep people here indefinitely.
Are they cremated and buried together?
No, they’re individual burials and we don’t cremate because ultimately some of these people will be identified and some of those families may not want cremation. If they prefer cremation, they can always have the body exhumed. Each municipality has arrangements with cemeteries for individual plots.
If there are religious requirements, like time or type of burial, what happens if you need to retain the body or elements of it?
For someone who is identified, we know the religious and cultural wishes of the family and we try and work as closely as possible to respect all of those wishes. There are some cases where we still must do an autopsy. We can’t say in the case of a homicide that we can’t do it. That doesn’t fit with the administration of justice or with societal expectations, but we’ll do everything we can not to do an autopsy if there’s a religious or cultural objection and it may not be critical to do so. In cases where there is religious desire to have burial within a short period of time, we’ll prioritize those cases and try to have them done as early as possible so the family can move on with funeral arrangements.
There may be concern about the retention of an organ, most commonly the heart or brain. Families are then always informed and they have the option of having the body held while we do our examination and have the organ returned to the body, or if the family prefers, they can carry-on with funeral arrangements and we’ll make arrangements to have that organ returned at a later time through a funeral service. In most cases, the family don’t wish to have the organ returned but we will do so either through cremation or burial.
How would you prepare for a mass influx of bodies due to a mass fatality?
It’s important to be prepared, so we do have a plan, and that mass fatality plan covers the range from a major plane crash to a potential terrorist act through to a pandemic where people are dying due to natural disease, and we have a number of steps and processes so that we can move bodies through as quickly as possible. I don’t want it to sound by any means that this is done with any disrespect. It’s a respectful process, but it has to be done with some efficiency. We have steps in place so we can deal with identification, storage, the autopsy, and we have a close link with the funeral industry because we need to have bodies picked-up.
Has the plan changed over the years?
This building is no longer appropriate for dealing with the types of cases that we may need to deal with in 2006 and beyond. The building is thirty years-old and thirty years ago there weren’t ventilation systems to deal with potential control of an airborne infection. When we dealt with SARS, it was unknown transmission so we could not do the autopsies here. They were done at Toronto General, which has a better facility with appropriate air-handling. When we were dealing with what turned-out to be the Legionnaires’ outbreak, at the time that was an unknown pathogen. We didn’t know what the transmissibility might be, so those cases were done at Toronto General.
Right now we’re moving toward having a newer facility, which will be larger and appropriately designed to deal with infectious agents and with some of the potential terrorist issues that we may need to deal with in the future that people weren’t thinking of thirty years ago.
What about the biohazardous waste?
In a newer facility, we would be able to deal with this better through drainage and appropriate handling. Right now, we collect the biohazardous material and it is taken off site.
Do you require a lot of interaction with other agencies outside of Ontario?
We are closely linked with other systems around the world. We were down in New York for three weeks assisting in the identification of Canadians after 9-11. At the time of the tsunami, there were three of us from our office that went to assist in Thailand, and we also assisted with the Swissair disaster. When it comes to international events, there’s very good co-operation.
Tell me about the RESOLVE Initiative.
We have now developed a website with the OPP for unidentified bodies, and that’s a very new initiative. We reach a point with our unidentified bodies where we have tried everything we can and we still can’t get them identified, so now we’re using the internet. We’ve had some early success and the OPP are managing to clear-up some cases of missing persons.
If a body or remains are found in Ontario, it would be incorrect to assume that we should only look in Ontario. British Columbia is in the process of launching a similar website; Saskatchewan has a smaller initiative, and these are going to develop across North America and across the world so that when we’re trying to identify these cases, we’re not just looking in Ontario for Ontario cases.
There are a large number of cases that have been found in Niagara Falls. Almost certainly, many of those are Americans or people from outside North America and we know that a number of these are suicides. People jump over the falls or into the gorge. We have to have a way of taking the information and get it out beyond Ontario.
How do you achieve balance between something so public and still having respect for the victims and their next of kin?
My goal is to put the best information we have in front of the public, but to do it in a sensitive and respectful manner. If the best information we have is a photograph that is taken at the time of autopsy, we’re going to use that photograph, but all of those images have been touched-up. They all have the same background and some of those cases include injuries or discolouration. We’ve adjusted all of that. We have lots of images that are just not appropriate to put on the site.
We are very clear that some people may find this information disturbing, but we’re dealing with over 150 cases going back to 1975 that we haven’t been able to identify. We were concerned that we might get some negative feedback, but that has not been the case.
The first thought that pops into my mind is that it will attract voyeurs.
We spent a lot of time trying to decide how to launch it. In the first few weeks after it was launched, there were 20,000 hits and we know there are still a lot of hits. I’m sure that some people go there just to look and we accept that’s going to happen, but we know that family and friends have also gone there and it’s resulted in us clearing cases.
You look on the site and you see how young some of these people are; you look at what they’re wearing and some of the characteristic findings like tattoos and jewelry and you’re thinking somebody has to know who that is.
Are there cases that are particularly fascinating and unusual?
The work itself is gratifying and it’s also interesting. That interest may come because we are seeing something that hasn’t been seen before or is very unusual, and the gratification may come from answering questions that otherwise wouldn’t have been answered. We’re also going beyond answering questions; we’re taking that information and using it to advance public safety. It’s gratifying to come across something and realize that a death under similar circumstances may not take place in the future if new strategies are put into place.
Are there certain cases that are tougher for your staff to deal with?
The staff deal with the most tragic of cases. Having said that, the work can be difficult. The death of children is always very difficult. The staff is appropriately educated and supported to deal with those cases.
On the news, mention of “the Coroner” always seems very mysterious. Are there misunderstandings about what coroners do?
It’s very important for our work that the public understand what we do and how we do it and don’t have unrealistic expectations. One of the misconceptions is that we’re involved in fault and blame and that we hold people accountable. There are other avenues to pursue that, whether it be federal courts or other regulatory bodies within the criminal justice system. We’re involved in answering the five questions and advancing public safety. With criminal cases, we’re not conducting the criminal investigation, but in a homicide, there may be ways to advance public safety. A good example of that would be domestic violence.
Do TV shows taint the public’s perception?
The pace is one that no system can possibly achieve. It takes much longer to do everything in reality. Many of our investigations take us weeks and sometimes months which you wouldn’t think by watching CSI or another forensic show. One also gets the impression that a single person does more that what they actually do. We’re more reliant on team function. We have expertise involving coroners, pathologists, police, forensic anthropologists, forensic entomologists, scientists — and it’s a larger team working on a case.
What do you think of the Body Worlds exhibit?
I was extremely impressed by it. I took my family, including our children, and I thought it was an excellent way for the public to learn about the body. Perhaps there was a little more drama and flare than what was necessary, but as someone who has gone through medical school and has learned about the body and seen parts of the body demonstrated, I’ve never seen it done better.
What have been the greatest advances in your field over the last few decades?
The most significant advances would be in biology with DNA testing, be it for identification or advancing a criminal investigation. Also, toxicology testing and some of the work that’s being done at the Centre for Forensic Sciences. With time, we learn more and more about disease and injury and how it affects the body. We learn new ways of investigating death to better understand what’s taken place.
Dr. Barry McLellan, MD, FRCPC was formerly the Deputy Chief Coroner and received his Doctorate and Fellowship from the University of Toronto. He is also an Associate Professor in the Department of Surgery, having written more than 60 scientific papers, a textbook on trauma care, and lectured extensively. The Office of the Chief Coroner is a division of the Ministry of Community Safety and Correctional Services.