Investigations of Non-work Related Fatalities - IPG-067

Effective Date: January 2009

1. Subject

To provide guidance to Managers and Health and Safety Officers, (HSO) on the investigation of fatalities that appear to be non-work related.

This IPG will address employee medical conditions and suicides, but not cover acts of violence which shall follow OPD 935-1 Hazardous Occurrence Investigations and Reporting.

Hazardous occurrence investigations, involving motor vehicles on public roads shall follow 935-1-IPG-066 Investigations of Motor Vehicle Accidents on Public Roads.

LCA Note: The appropriate assignment type for investigations conducted in accordance with this IPG is: Investigation Hazardous Occurrence - Fatality, but with the Result Code, "Fatality Non-work Related".

2. Issue

There have been cases where employees have died at work as a result of their own medical condition. There have also been employees who have committed suicide in the work place or while at work.

Therefore it is necessary to establish the extent and format of investigations required to be conducted by HSOs for employee deaths in the work place, that are not work related.

3. Questions

  1. Does every death of an employee in the work place need to be investigated by a HSO?
  2. What information should be gathered in the course of the investigation when non-work related causes are suspected?
  3. What is the format of the investigation report the HSO is required to produce?

4. Conclusions

  1. Does every death of an employee in the work place need to be investigated by a HSO?

    Yes, subsection 141.(4) of the Canada Labour Code requires a HSO to investigate every death of an employee that occurs in the work place or while the employee was working, or that was the result of a work place injury. An investigation is initiated in accordance with OPD 700-3 Priorities for Interventions - Group A.
  2. What information should be gathered in the course of the investigation when non-work related causes are suspected?

    It should not be assumed that the death of an employee who suddenly dies in the work place is a non-work related fatality, even if the employee had previously complained of chest pains. For example, a HSO may learn that the employee was normally an office worker and had spent the morning doing manual labour in a warehouse, or had been wearing a respirator for the first time and had not been medically assessed to determine if he was fit enough for the slight restriction in breathing caused by the respirator.

    As is the case during any fatality investigation, the HSO should show empathy and understanding when dealing with the co-workers or any family members of the deceased.

    The HSO must gain a good understanding of what the employee was doing before his death, the first aid treatment he received at the time of the incident, and how the work place emergency response functioned.

    Perhaps the most helpful piece of information in determining whether or not a death is work related will be the Medical Examiner/Coroner's report. These reports provide information regarding the cause of death and should be requested in writing, as soon as possible, using the template letter in Appendix C . However Coroners are not required to provide HSOs with copies of their reports and may refuse to do so.

    If the HSO obtains Medical Examiner/ Coroner or Police reports containing evidence of alcohol, prescription or illicit drug use, the HSO must treat this information in accordance with OPD 900-2 Substance Abuse Intervention.

    If a Coroner's report indicates that an employee's death is not work related, but the investigating HSO suspects there may be a causal factor(s) in the work place, a discussion with the Technical Advisor OHS is required to decide on the need to involve Technical Services at NHQ and/or a Medical Consultant retained by the Labour Program, to determine the appropriate course of action.

    Employee suicides at work, or while working, will also necessitate an investigation by a HSO. In these cases, the HSO should determine whether or not there were any contributing work place factors i.e. impending job loss, poor performance review, work place harassment, etc.

    If after this consultation the HSO believes work place conditions contributed to the employee's death, he shall conduct the investigation in accordance with
    OPD 935-1 Hazardous Occurrence Investigations and Reporting.
  3. What is the format of the investigation report the HSO is required to produce?

    Following the investigation, if it is determined that the death is not related to the employee's work, the HSO shall prepare a report containing the information in Appendix A , where that information is available. Within 10 days of completing the report, the HSO shall provide a copy of the report to the employer and work place health and safety committee or representative, in accordance with subsection 141.(6) of the Code, along with a cover letter containing the information in Appendix B . However the report shall not include photographs, witness statements, police or Medical Examiner/coroner reports, or any other documents obtained from a third party.

    If it is determined that the death is related to the employee's work, refer to OPD 935-1 Hazardous Occurrence Investigations and Reporting.

Fulvio Fracassi
Director General
Program Development and Guidance Directorate
HRSDC-Labour Program


Appendix A: Hazardous Occurrence Investigation Report

**Where input is necessary**

Canadian flag with the text Government of Canada

Human Resources and Skills Development Canada - Labour Program
Address of the District Office

Hazardous Occurrence Investigation Report
Under Subsection 141.(6) of the Canada Labour Code, Part II

Related to the **Fatality or Injury** of **Name of Employee**

Occurring at Work

on **Date of Occurrence**

Employed by: **Name and address of Employer**

Prepared by: **Name of investigating Office** Health and Safety Officer

Assignment Number:

Date of Report:

Table of Contents

1.0 General Information
1.1 Summary of the hazardous occurrence
1.2 Date and time Labour Program was notified
1.3 Identification of the Officer assigned to the file
1.4 Identification of other interveners

2.0 Information on the Work Place
2.1 Description of the company, its employees and its activities
2.2 Health and safety contacts

3.0 Details of the Hazardous Occurrence
3.1 Description of the hazardous occurrence

4.0 Action and Follow-up by the Health and Safety Officer
4.1 Conclusion
4.2 Directions issued or AVC's received
4.3 Recommendations


1.0 General Information

1.1 Summary of the hazardous occurrence
(Date, time, location, description of the hazardous occurrence)

1.2 Date and time Labour Program was notified

1.3 Identification of the Officer assigned to the file

1.4 Identification of other interveners
(Medical Examiner/Coroner, police, witnesses, concerned third parties)

2.0 Information on the Work Place

2.1 Description of the company, its employees and its activities
(Address, number of employees, its specialty, etc.)

2.2 Health and safety contacts
(Local Work Place Health and Safety Committee Members/Representative)
(Company Safety Department personnel)

3.0 Details of the Hazardous Occurrence

3.1 Description of the hazardous occurrence
(Work being done at the time, equipment used)
(Witness observations)
(Environmental conditions)
(Description of employee's injuries or condition)
(Description of First Aid and emergency measures provided)

3.2 Analysis of the Causal Factors
(Any strenuous work performed by employee in previous 24 hours)
(Medical Examiner/Coroner's findings regarding cause of death)

4.0 Action and Follow-up by the Health and Safety Officer

4.1 Conclusion
(Actions the employer has taken to prevent a re-occurrence)

4.2 Directions issued or AVC's received

4.3 Recommendations

Signature

**Signature**
Health and Safety Officer
Identification Number:

Appendix B: Cover Letter for Hazardous Occurrence Investigation Report

**Where input is necessary**

**Date**

Assignment **No.**

**Name and address of Employer**

Dear **Mr./Mrs./Ms.**:

RE: Hazardous Occurrence Investigation Report
Work place **Fatality or Injury** of **Name of employee** on **date**

In accordance with subsection 141.(6) of the Canada Labour Code, Part II , please find enclosed a copy of the above report.

A copy of this report is also being sent to the Work Place Health and Safety **Committee or Representative** for your work place.

If you have any questions regarding this matter, do not hesitate to contact the undersigned.

Yours sincerely,

**Name**,
Health and Safety Officer **ID#**

HRSDC-Labour Program
**address**

**Telephone**, **Fax**
**Complete mailing address if not on letterhead**

cc. Work Place Health and Safety **Committee or Representative**

Encl.

Appendix C: Letter to the Medical Examiner/Coroner

**Where input is necessary**

**Date**

Office of the **Medical Examiner/Coroner**
**Address**

Attention: **Dr./Mr./Ms/Designate on behalf of Medical Examiner/Coroner**

Subject: Request for Reports concerning the Cause of Death of **Name of Employee**.

I am a Health and Safety Officer with Human Resources and Skills Development Canada - Labour Program. I am investigating the work place fatality of **Name of Employee** who died on **Date**, in the employ of **Name of Employer**. This investigation is being conducted in accordance with subsection 141.(4) of the Canada Labour Code, Part II , which applies to federally regulated employers.

141.(4) A health and safety officer shall investigate every death of an employee that occurred in the work place or while the employee was working, or that was the result of an injury that occurred in the work place or while the employee was working.

As lead investigator, in this matter, I respectfully request copies of all reports concerning the cause of death of **Name of Employee**, including any autopsy and toxicology reports.

Please forward copies of these reports to my attention at the address below. Thank you in advance for your cooperation in this matter. Should you have any questions, please contact me directly.

**Name of HSO**
Health and Safety Officer **ID#**

HRSDC-Labour Program
**address**

**Telephone**, **Fax**

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