BC Coroner Services

March 25, 2022

Billie Joe serves on the BC Coroner Services Death Review Panel.


A death review panel is mandated2 to review and analyze the facts and circumstances of deaths to provide the chief coroner with advice on medical, legal, social welfare and other matters concerning public health and safety and prevention of deaths.

A death review panel may review one or more deaths before, during or after a coroner’s investigation, or inquest.

Panel members were appointed by the chief coroner under Section 49 of the Coroners Act, including professionals with expertise in public health, health services, substance use, mental health, Indigenous health, education, income assistance, child welfare, youth services, policing and academia.

Regardless of their employment or other affiliations, individual panel members were asked to exercise their mandate under the Coroners Act and express their personal knowledge and professional expertise. The findings and recommendations contained in this report need not reflect, or be consistent with, the policies or official position of any other organization.

In the course of reviewing deaths of youth transitioning from government services, the panel reviewed:

  • BCCS investigative findings;
  • Information provided by panel members;
  • Environmental, social and medical factors associated with the deaths;
  • Possible trends or themes;
  • The current state of related public policy and strategies; and,
  • Existing challenges.

The panel collectively identified actions for improving public health prevention processes with respect to deaths among youth transitioning from care.

Click here to view and download the full BC Coroner Services Death Review Panel: Review of MCFD-Involved Youth Transitioning to Independence January 1, 2011 – December 31, 2016: PDF