Advocating for adherence to Coroners Service Inquest recommendations.

BCSS aims to:

Ensure that agencies are receiving the recommendations issued to them by the Coroners Service inquest, and enacting the appropriate changes to protect the wellbeing of people living with a mental illness and their families.


The BC Coroners Service is responsible for investigating unnatural, sudden, and unexpected deaths and identifying and advancing recommendations to individuals, groups, and agencies aimed at prevention of death in the future under similar circumstances. These recommendations provide an opportunity to improve services for the mentally ill and their families and need to be closely monitored.

In 2013, the BC Schizophrenia Society undertook a review of inquest recommendations that have been issued by the BC Coroners Service since 2008 in response to deaths related to mental illness. Key recommendations have been chosen for follow-up and the various agencies have been contacted regarding their response to the recommendations.


Thus far, 17 cases involving a mental illness have been identified resulting in 196 recommendations to approximately 40 different policing, government, health, education or justice agencies. We have contacted 17 of those agencies to inquire about their response to specific recommendations and have received a response from every agency listed below:

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