Ontario's Office of the Chief Coroner is reviewing 132 cases in which some of the province's top-billing coroners investigated the death of a person they'd treated within five years of their demise.

The potential conflicts of interest were not declared in 95 per cent of those cases despite established policy, according to a nearly 60-page section of the Ontario auditor general's annual report released last week.

"These cases are concerning because there is a risk that the truth about a death will not come to light if the physician's treatment decisions while the patient was alive could have contributed to the patient's death," according to the report.

Coroners are medical doctors who've completed a five-day course on conducting death investigations. They don't perform autopsies, but they do decide whether or not to order one.

"I was surprised by the findings, because we do educate the coroners," said Dr. Dirk Huyer, Ontario's chief coroner.

"We do inform the coroners that if there is a potential conflict of interest … we have a process of notification and consideration."

One case the report flagged involved a Toronto coroner who saw his patient roughly once a week in the four years before the patient's death. The coroner practised addiction medicine and was prescribing the patient methadone, but did not report he was the prescribing physician as part of his death investigation.

Surgeon acts as coroner on patient week after surgery

In another case, an orthopaedic surgeon in Oshawa oversaw surgery to repair a hip fracture. A week later, the patient died in hospital and the same surgeon then investigated the death without declaring a conflict of interest, according to the auditor general's report.

The surgeon wrote there were "no care concerns" in the coroner's report and decided not to conduct an autopsy even though they found that the cause of death was complications from a hip fracture.

Huyer told CBC Toronto that cases like these raise serious concerns.

"Unfortunately we do have circumstances out of our 17,000 investigations we do per year where things don't go as they should," said Huyer. "In those cases we are taking it very seriously."

Ontario Chief Coroner Dr. Dirk Huyer was surprised by the auditor general's findings because he says his office does educate coroners on its process for dealing with conflicts of interest. (CBC)

In fact, the auditor general found that some of the circumstances she discovered could meet the bar for professional misconduct under the Coroner's Act — which would require the Office of the Chief Coroner to report those doctors to the College of Physicians and Surgeons of Ontario (CPSO).

Huyer isn't ruling out making that referral for some cases, but told CBC Toronto it hasn't happened yet, and won't, until his office has a "clear evaluation" of what happened in each case.

"We have a systematic approach that we are evaluating each of them, all 132," he said. "Those that are more serious have more serious evaluation, and more serious potential consequences."

In addition to the 132 flagged cases from 19 coroners who treated people within five years of their death, the auditor general's report also narrowed the scope down to care provided within one year of death.

In that time frame, 15 of the 23 top-billing coroners from 2018 investigated the deaths of 54 former patients.

In her annual report, Auditor General Bonnie Lysyk says there's a risk that the truth will not come to light in some cases where coroners investigate the deaths of people they'd previously treated. (The Canadian Press)

However, Huyer points out that his office's early evaluation has found some of these cases involved doctors who worked in a walk-in clinic or emergency room where they saw a patient once, sometimes many months before their deaths for an unrelated ailment.

Small towns also present difficulties because there might only be one coroner working in the area.

"There are times when there will be coroners involved with their patients," Huyer told CBC Toronto. "But the most important thing is that we as the management team, and the supervisory team, are aware of it."

One of the reasons Huyer says he wasn't aware of the flagged cases is because his office didn't have access to OHIP billing records.

Since the auditor general's office shared its findings, his office has obtained access and Huyer plans to work with the Ministry of Health and CPSO to "ensure that we have an effective way to capture this kind of thing happening."

Coroners to disclose treatment of deceased when assigned

The Office of the Chief Coroner will also revise its conflict of interest policy to clearly outline examples of what is, and isn't a potential conflict.

And coroners will soon be required to fill in a mandatory field when they accept a case disclosing whether they have treated a deceased person when the office's new IT system launches next year.

If the coroner has treated the patient, the case will then be reviewed by a supervising coroner — the same protocol as before if a coroner reported a conflict.

"We want to have a defined process," said Huyer. "We want to make sure that coroners have the trigger to be able to recognize, and think about this early, as they take the case."

In the meantime, Huyer told CBC Toronto he sent the auditor general's report to all coroners highlighting the conflict of interest issue, among others.