Confirmed and Suspected Drug Toxicity Deaths

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

The data in the following tables include all death investigations concluded by the Saskatchewan Coroners Service (SCS) between January 1, 2010 and September 2, 2021 where the cause of death was due to a Drug Toxicity (Single or Combined Drug Toxicity). The statistics shown are subject to change as new investigations are undertaken and/or on-going investigations are concluded.

For the following tables please note: • ‘Undetermined’ indicates that after completing an investigation, there is equal evidence, or a significant contest between one or more classifications. • The statistics for 2019, 2020 and 2021 are preliminary given that not all death investigations for these years have been concluded. • All statistics in these tables have been confirmed drug toxicity deaths with the exception of the table “Suspected Drug Toxicity Deaths, January 1 to December 31, 2020” and “Suspected Drug Toxicity Deaths, January 1, to September 2, 2021”. At the time of this printing, the statistics in this particular table are preliminary data and may change once the cases have been concluded.

Confirmed Drug Toxicity Deaths by Manner of Death, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Accident 52 56 60 62 67 91 92 95 139 154 285 93 Suicide 21 24 17 21 13 23 13 16 27 21 17 5 Homicide ------0 Undetermined 5 6 9 5 5 7 4 8 6 4 1 4 Total 78 86 86 88 85 121 109 119 172 179 303 102

Suspected Drug Toxicity Deaths, January 1, 2020 to December 31, 2020 Total 36* Suspected Drug Toxicity Deaths, January 1, 2021 to September 2, 2021 Total 167* *At the time of this printing, this is preliminary data and these numbers are SUSPECTED drug deaths. These numbers may change once the cases have been concluded. *To provide an aggregate number for 2020, please add the Suspected Drug Toxicity Deaths to the 2020 Confirmed Drug Toxicity Deaths shown above. To provide an aggregate number for 2021, please add the Suspected Drug Toxicity Deaths to the 2021 Confirmed Drug Toxicity Deaths shown above.

Source: Saskatchewan Coroners Service 1

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Breakdown of Opioid Drugs Identified in Confirmed Drug Toxicity Deaths by Manner of Death, 2010 – 2021 Opioid Buprenor- Acetyl Monoacetyl Meperidine Furanyl Furanyl Para- Codeine Fentanyl Heroin Hydrocodone Hydromorphone Methadone Morphine Oxycodone W-18* Carfentanyl (Unknown) phine fentanyl morphine Fentanyl UF-17 fluorofentanyl 2010 Accident 4 2 -- -- 12 11 12 10 ------Suicide 2 ------2 -- 3 ------Homicide ------Undetermined ------3 1 1 ------2011 Accident 7 2 -- -- 19 20 12 5 ------Suicide 2 ------1 3 3 4 ------Homicide ------Undetermined -- 1 -- -- 3 1 ------2012 Accident 12 6 1 -- 16 14 19 3 ------Suicide 4 ------1 1 -- 2 ------Homicide ------Undetermined 2 1 ------2 2 2 ------2013 Accident 3 9 -- -- 17 21 10 7 1 ------Suicide 2 1 -- -- 4 2 4 1 ------Homicide ------Undetermined ------2 2 -- 1 ------2014 Accident 5 9 -- -- 22 20 15 4 ------2 ------Suicide -- 2 -- -- 1 4 2 1 ------Homicide ------Undetermined ------1 -- 1 2 ------2015 Accident 10 21 -- -- 30 27 21 5 -- 1* ------Suicide 1 1 -- -- 4 2 3 2 ------Homicide ------Undetermined 1 ------3 -- 3 ------2016 Accident 8 8 1 -- 26 34 20 4 ------Suicide 1 ------1 2 ------Homicide ------Undetermined 1 1 -- -- 1 1 ------Source: Saskatchewan Coroners Service 2

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Breakdown of Opioid Drugs Identified in Confirmed Drug Toxicity Deaths by Manner of Death, 2010 – 2021 Opioid Buprenor- Acetyl Monoacetyl Meperidine Furanyl Furanyl Para- Codeine Fentanyl Heroin Hydrocodone Hydromorphone Methadone Morphine Oxycodone W-18* Carfentanyl (Unknown) phine fentanyl morphine Fentanyl UF-17 fluorofentanyl 2017 Accident 14 14 -- 5 28 30 27 3 ------4 ------Suicide 3 -- -- 1 7 1 2 ------Homicide ------Undetermined -- 1 -- -- 1 2 1 1 ------2018 Accident 14 46 _ 7 41 38 27 8 _ _ 1 6 -- 7 ------Suicide 7 1 _ 1 2 1 9 4 _ _ ------2 ------Homicide ______------Undetermined _ _ _ _ _ 1 _ _ _ _ ------2019 Accident 13 43 -- 5 56 45 36 5 -- -- 1 4 10 3 ------Suicide 3 ------7 -- 2 ------Homicide ------Undetermined ------2 ------2020 Accident 22 151 -- 8 84 45 42 5 -- -- 4 6 131 1 -- 1 2 -- Suicide 4 3 -- -- 6 -- 3 ------2 ------Homicide ------Undetermined -- 1 ------2021 Accident 1 67 -- 1 12 7 8 ------2 59 ------1 3 Suicide -- 2 -- -- 1 ------2 ------Homicide ------Undetermined ------2 ------

* Illicit Drugs Containing W-18 – As part of a 2015 investigation into the combined drug toxicity death of a male, age 25, there were tablets found at the scene which were analyzed and found to contain fentanyl and W-18. Given the limitations of toxicology testing, it is not possible to quantify W-18 beneath a certain level within a person’s blood. The Saskatchewan Coroners Service was unable to determine whether W-18 contributed to this individual’s death. Also, based on the circumstances of the death, it could not be confirmed whether the deceased ingested any of the tablets that contained the fentanyl and W-18. The individual’s cause of death was combined drug toxicity involving a number of drugs including fentanyl and morphine which are reflected in the statistics contained in the tables of this report.

Source: Saskatchewan Coroners Service 3

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Confirmed Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death, Gender and Race, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Accident Female Caucasian 7 5 5 6 6 10 10 12 19 11 25 10 First Nations (status & non-status) 3 7 8 9 9 11 15 17 25 30 47 16 Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis - - - - - 3 1 - 2 2 6 - Other Specified Race ------Unknown - 1 - 4 5 3 5 3 3 4 3 3 Total Female 10 13 13 19 20 27 31 32 49 47 81 29 Male Caucasian 16 17 14 16 18 25 19 23 36 33 65 20 First Nations (status & non-status) 11 15 17 14 13 20 15 18 15 30 73 23 Asian 1 1 - - - - 1 - 1 - 3 - Black/African American - - - - - 1 1 - - - 1 1 Hispanic or Latino ------Inuit ------Metis - - - - 1 - 5 2 2 2 4 1 Other Specified Race ------1 - - - 2 - Unknown 2 4 6 3 7 6 3 1 11 11 10 3 Total Male 30 37 37 33 39 52 45 44 65 76 158 48 Total Female and Male 40 50 50 52 59 79 76 76 114 123 239 77 ** Please note that this table replaces the former table Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death and Gender, 2010 –2019. This current table includes Manner of Death, Gender and Race.

Source: Saskatchewan Coroners Service 4

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Confirmed Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death, Gender and Race, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Suicide Female Caucasian 3 2 3 5 4 3 2 6 6 4 6 - First Nations (status & non- 1 2 2 - 3 1 1 - 2 1 - 1 status) Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis ------1 - - - - - Other Specified Race ------Unknown ------Total Female 4 4 5 5 7 4 4 6 8 5 6 1 Male Caucasian 1 7 1 3 1 4 - 4 4 4 4 1 First Nations (status & non- 1 - 1 1 - - - - 1 2 - - status) Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis ------Other Specified Race ------Unknown - 1 - 3 - 1 ------Total Male 2 8 2 7 1 5 0 4 5 6 4 1 Total Female and Male 6 12 7 12 8 9 4 10 13 11 10 2 ** Please note that this table replaces the former table Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death and Gender, 2010 –2019. This current table includes Manner of Death, Gender and Race.

Source: Saskatchewan Coroners Service 5

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Confirmed Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death, Gender and Race, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Homicide Female Caucasian ------First Nations (status & non------status) Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis ------Other Specified Race ------Unknown ------Total Female 0 0 0 0 0 0 0 0 0 0 0 0 Male Caucasian ------First Nations (status & non------status) Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis ------Other Specified Race ------Unknown ------Total Male 0 0 0 0 0 0 0 0 0 0 0 0 Total Female and Male 0 0 0 0 0 0 0 0 0 0 0 0 ** Please note that this table replaces the former table Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death and Gender, 2010 –2019. This current table includes Manner of Death, Gender and Race.

Source: Saskatchewan Coroners Service 6

DRUG TOXICITY DEATHS

Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Confirmed Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death, Gender and Race, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Undetermined Female Caucasian 1 1 2 1 1 1 2 1 - 1 - - First Nations (status & non- - 1 - 1 - 1 - 1 - 1 - - status) Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis ------Other Specified Race - 2 ------Unknown - - - 2 - - - 1 - - - - Total Female 2 3 3 3 2 1 3 2 1 1 0 0 Male Caucasian 2 1 2 2 - 3 - 1 - 1 - 1 First Nations (status & non- 1 1 1 - - - 2 - - 1 - 1 status) Asian ------Black/African American ------Hispanic or Latino ------Inuit ------Metis ------Other Specified Race ------Unknown ------Total Male 3 2 2 2 0 5 0 1 1 1 1 2 Total Female and Male 5 5 5 5 2 6 3 3 2 2 1 2 ** Please note that this table replaces the former table Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death and Gender, 2010 –2019. This current table includes Manner of Death, Gender and Race.

Source: Saskatchewan Coroners Service 7

DRUG TOXICITY DEATHS Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated – September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Confirmed Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death, Gender and Age Group, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Accident Female 0 – 9 ------10 – 19 ------2 -- 3 -- -- 4 1 20 – 29 -- 2 1 4 2 7 3 12 10 11 15 6 30 – 39 1 5 4 6 8 4 13 5 13 12 21 12 40 – 49 6 2 3 5 5 10 6 3 10 13 14 4 50 – 59 3 3 2 3 3 4 7 4 13 10 17 4 60 – 69 1 1 3 2 1 -- 2 5 3 -- 10 2 70 – 79 1 ------1 ------80 + ------1 -- -- Male 0 – 9 ------1 ------10 – 19 1 -- 1 1 1 4 ------1 3 -- 20 – 29 3 12 15 7 9 14 6 9 16 15 29 10 30 – 39 5 10 3 3 12 14 21 12 18 21 49 11 40 – 49 11 11 7 10 10 14 4 13 12 15 36 11 50 – 59 3 4 9 9 5 6 9 8 11 19 29 13 60 – 69 -- -- 2 1 2 -- 4 1 6 4 10 3 70 – 79 ------1 1 2 1 1 -- 80 + ------1 -- Total 40 50 50 52 59 79 76 76 114 123 239 77 Suicide Female 0 – 79 4 4 5 5 6 4 4 6 8 5 6 1 80 + ------1 ------Male 0 – 19 ------20 – 29 -- 1 -- 1 ------3 1 1 1 30 – 39 -- 4 2 2 1 ------40 – 49 2 -- -- 3 -- 3 -- 1 ------50 – 80 + -- 3 -- 1 -- 2 -- 3 2 5 3 -- Total 6 12 7 12 8 9 4 10 13 11 10 2 Homicide Female 0 – 80 + ------Male 0 – 80 + ------Total ------0 0 Undetermined Female 0 – 19 -- 1 ------20 – 29 -- 1 1 ------1 -- 1 ------30 – 80 + 2 1 2 3 2 1 2 2 -- 1 -- -- Male 0 – 80 + 3 2 2 2 -- 5 -- 1 1 1 1 2 Total 5 5 5 5 2 6 3 3 2 2 1 2 Total 51 54 62 69 69 94 83 89 129 136 250 81 ** Please note that this table replaces the former table Drug Toxicity Deaths Involving Opioid Drugs by Manner of Death and Age Group, 2010 – 2018. This current table includes Manner of Death, Age Group AND Gender. Source: Saskatchewan Coroners Service 8

Confirmed Drug Toxicity Deaths Involving Fentanyl by Manner of Death, Gender and Age Group, 2010 – 2021 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Accident Female 0 – 9 ------10 – 19 ------2 -- -- 3 1 20 – 29 -- 1 -- 1 -- 3 -- 2 2 7 13 6 30 – 39 ------1 1 -- 1 -- 7 3 13 12 40 – 49 ------1 -- -- 2 2 6 4 50 – 59 1 ------1 2 2 5 2 60 – 69 ------1 -- -- 1 1 70 – 79 ------80 + ------Male 0 – 9 ------10 – 19 ------1 2 ------1 1 -- 20 – 29 -- 1 4 5 3 8 1 3 12 6 23 9 30 – 39 ------1 3 3 5 2 12 14 41 10 40 – 49 -- -- 1 1 1 4 -- 2 5 4 25 11 50 – 59 -- -- 1 ------1 3 3 17 9 60 – 69 ------1 ------3 2 70 – 79 1 ------1 1 -- -- 80 + ------Total 2 2 6 9 9 21 8 14 46 43 151 67 Suicide Female 0 – 29 ------1 30 - 39 ------1 ------1 -- 40 - 49 ------50 - 59 ------1 -- 60 - 79 ------80 + ------Male 0 – 19 ------20 – 29 ------1 ------1 -- 1 1 30 – 39 ------1 ------40 – 49 ------1 ------50 – 80 + ------Total ------1 2 1 -- -- 1 -- 3 2 Homicide Female 0 – 80 + ------Male 0 – 80 + ------Total ------0 Undetermined Female 0 – 19 ------20 – 29 -- 1 1 ------1 ------30 – 80 + ------1 ------Male 0 – 80 + ------1 -- Total -- 1 1 ------1 1 -- -- 1 0 Total 2 3 7 10 11 22 9 15 47 43 155 69

Source: Saskatchewan Coroners Service 9

Confirmed Drug Toxicity Deaths by Place of Death, 2020 & 2021 2020 2021 Saskatoon 73 30 Regina 130 51 Aberdeen 1 - Ahtahkakoop Cree Nation 2 - Antler 1 - Big Island Cree Territory 1 - Briercrest 1 - Buffalo Narrows 1 - Canoe Narrows 1 - Colonsay 1 - Cote First Nation 1 - Cowessess First Nation - 1 Craven - 1 Cupar 1 - Cumberland House - 1 Esterhazy - 1 Estevan 1 - Fort Qu’Appelle 2 - Golden Prairie 1 - Good Spirit Acres 1 - Gordon’s First Nation 3 1 Guernsey 2 - Hudson Bay 1 - Humboldt 1 1 Ila a la Crosse 1 - Kamsack 1 - Langenburg 1 - La Loche 1 - La Ronge 1 - Leader - 1 Lebret 1 - Little Black Bear First Nation 1 - Little Red First Nation 1 - Lloydminster 9 1 Marshall 1 - Martensville 1 - McLean 1 - Melfort 1 - Melville 1 - Moose Jaw 6 1 Mosquito First Nation 1 - Muskeg Lake Cree Nation 1 - Muskowekwan First Nation 1 1 Nipawin 1 - North Battleford 3 1 Odessa 1 - Peepeekisis First Nation - 1 Pelly 1 - Prince Albert 4 2 Piapot First Nation 1 - Pierceland 1 - Radisson 1 - Shellbrook 1 - Spalding - 1 Star Blanket Cree Nation - 1 Stoughton 1 - St. Walburg 1 - Sweetgrass First Nation 1 1 Swift Current 1 1 Tatallon 1 - Pasqua First Nation 3 - Pilot Butte 1 - Prince Albert 6 - Red Pheasant First Nation 1 - Regina Beach - 1 Spiritwood 1 - Swift Current 1 - Unity 1 - Vibank 1 - Viscount 1 - Wadena 1 - Weyburn 1 1 White Bear First Nation 1 - Uranium City 1 - Yorkton 7 1 Total 303 102

Source: Saskatchewan Coroners Service 10

Breakdown of Fentanyl (F), Carfentanyl (C),Acetylfentanyl (A), Furanylfentanyl (FF) & Para-fluorofentanyl Identified in Confirmed Drug Toxicity Deaths by Place of Death, 2013 – 2021

2013 2014 2015 2016 2017 2018 2019 2020 2021 F C F C F C A F C A FF F C A FF PF Saskatoon 6 4 12 1 9 1 13 2 16 3 5 33 1 29 -- 16 2 16 -- 1 Regina 2 3 -- 5 4 3 23 3 20 1 4 92 3 79 1 41 -- 34 -- 1 Aberdeen ------1 -- 1 ------Assiniboia ------1 ------Battleford -- 1 1 ------Beauval -- 1 ------Big River ------1 ------Canora ------1 ------Colonsay ------1 -- 1 ------Cowessess First Nation ------1 -- 1 -- -- Craven ------1 -- 1 -- -- Cupar ------1 -- 1 ------Esterhazy ------1 -- 1 -- -- Estevan ------1 ------1 -- 1 ------Fort Qu’Appelle ------1 -- 1 ------Gordon’s First Nation ------2 1 1 -- 1 ------Guernsey ------1 -- 1 ------Humboldt ------1 ------Indian Head ------1 ------Kawacatoose First Nation ------1 ------Kindersley 1 1 1 1 -- -- 1 ------Kindersley Community -- -- 1 ------Langenburg ------1 -- 1 ------La Ronge ------1 -- 1 ------Lloydminster -- 1 ------1 ------5 1 4 -- 1 -- 1 -- -- Maidstone ------2 ------Marshall ------1 ------Martensville ------1 -- 1 ------Melfort ------1 -- 1 ------Melville ------1 -- 1 ------McLean ------1 -- 1 ------Melfort ------1 ------Moose Jaw -- -- 1 1 ------1 -- 1 ------Muskowekwan First Nation ------1 -- 1 -- 1 -- 1 -- -- North Battleford ------1 -- 1 -- -- Odessa ------1 -- 1 ------Pelly ------1 -- 1 ------Peepeekisis First Nation ------1 -- 1 -- 1 Piapot First Nation ------1 -- 1 ------Radville ------1 ------Radisson ------1 -- 1 ------Regina Beach ------1 -- 1 -- -- Shaunavon ------1 ------Shell Lake ------1 ------Sweetgrass First Nation ------1 -- 1 -- -- Swift Current 1 -- 1 ------1 -- 1 -- -- Pasqua First Nation ------1 ------Pilot Butte ------1 ------Prince Albert -- -- 1 ------1 ------2 -- 2 ------RM of Pleasantdale -- -- 1 ------RM of Wilton ------1 ------Rosthern -- -- 1 ------Unity ------1 ------Warman ------1 ------Weyburn ------1 ------1 -- 1 -- -- Weyburn Community -- -- 1 ------Wynyard -- -- 1 ------Yorkton -- -- 1 ------1 ------1 -- 1 ------Total 10 11 22 9 15 4 47 6 43 4 10 155 6 133 1 69 2 61 0 3 Source: Saskatchewan Coroners Service 11

DRUG TOXICITY DEATHS Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated –September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Confirmed Drug Toxicity Deaths Related to Fake OxyContin by Place of Death, 2013 – 2021

2013 2014 2015 2016 2017 2018 2019 2020 2021 Saskatoon 1 2 4 -- 1 ------Kindersley -- 1 ------Prince Albert -- -- 1 ------RM of ------1 ------Pleasantdale Total 1 3 6 -- 1 ------

Confirmed Drug Toxicity Deaths Related to Fake OxyContin by Manner of Death, Gender and Age Group, 2013 – 2021 2013 2014 2015 2016 2017 2018 2019 2020 2021 Accident Female 0 – 80 + ------Male 10 – 19 -- 1 1 ------20 – 29 1 2 4 -- 1 ------40 – 49 -- -- 1 ------Total 1 3 6 -- 1 ------Suicide Female 0 – 80 + ------Male 0 – 80 + ------Total ------Homicide Female 0 – 80 + ------Male 0 – 80 + ------Total ------Undetermined Female 0 – 80 + ------Male 0 – 80 + ------Total ------Total Female 0 – 80 + ------Male 0 – 80 + 1 3 6 -- 1 ------

Source: Saskatchewan Coroners Service 12

DRUG TOXICITY DEATHS Saskatchewan Coroners Service Saskatchewan, 2010 to 2021 (Confirmed Drug Toxicity Deaths Updated –September 2, 2021) (Suspected Drug Toxicity Deaths Updated – September 2, 2021)

Number of Confirmed Deaths Where Methamphetamine Toxicity was Part of the Cause of Death, 2013 - 2021 Deaths Where Cause of Deaths Where Cause of Death Was Solely From Death Was Due to a Year Methamphetamine Combined Drug Toxicity Total Toxicity With Methamphetamine Being Identified as One of the Drugs 2013 1 0 1 2014 0 3 3 2015 1 8 9 2016 1 21 22 2017 4 20 24 2018 7 41 48 2019 13 34 47 2020 11 113 124 2021 8 47 55

Source: Saskatchewan Coroners Service 13