TORONTO — Ontario’s Office of the Chief Coroner has announced a mandatory inquest into the death of Robert Twiss, a 47-year-old man who died while in custody at the Central North Correctional Centre in Penetanguishene in 2018.
Dr. Kenneth Peckham, Regional Supervising Coroner for the Central Region, Central West Office, confirmed the proceeding this week. “An inquest will be held into the death of Robert Twiss,” Dr. Peckham said in a statement released by the Ministry of the Solicitor General.
Circumstances of the Case
Mr. Twiss died on December 3, 2018, while serving time at the Central North Correctional Centre, a provincial facility located in Midland–Penetanguishene that houses both remanded and sentenced inmates. His death triggered the requirement for an inquest under Ontario’s Coroners Act, which makes such reviews mandatory when an individual dies in custody.
While specific details of Mr. Twiss’s case have not yet been released publicly, the inquest will focus on examining the events leading to his death and any systemic factors that may have contributed.
Purpose of the Inquest
According to the Office of the Chief Coroner, inquests in Ontario are not trials but public hearings aimed at preventing similar tragedies in the future. A five-member jury hears testimony from witnesses, reviews evidence, and delivers findings of fact. At the conclusion, the jury may make recommendations to improve policies, procedures, or institutional practices.
“The inquest will examine the circumstances surrounding Mr. Twiss’ death. The jury may make recommendations aimed at preventing further deaths,” Dr. Peckham’s statement said.
Such recommendations, while not legally binding, often influence policy decisions across the corrections, health care, and justice systems.
Next Steps
The Ministry of the Solicitor General noted that details about the date, venue, and presiding coroner will be released once arrangements are finalized. Inquests are typically held in or near the community where the death occurred, though remote or hybrid proceedings have become more common in recent years.
Families of the deceased are usually given standing at the hearings, alongside government ministries, correctional authorities, and organizations with a direct interest in the issues raised. Legal counsel is often provided to ensure the proceedings address concerns thoroughly.
Broader Context
Ontario holds dozens of mandatory inquests each year into deaths that occur in custody, in the workplace, or in other specific circumstances defined by law. These inquiries are part of the province’s efforts to provide public accountability and identify opportunities to improve safety.
For correctional institutions in particular, inquests have historically raised issues such as inmate health care, mental health supports, staff training, and facility oversight. Past recommendations have led to reforms in suicide prevention protocols, medical monitoring, and crisis response procedures within provincial jails
Public Information
The province emphasized that further information will be made available closer to the start of the hearings. A resource page on the Ontario government’s website outlines the purpose and procedures of coroner’s inquests, as well as previous findings and recommendations.
“For more information about inquests, see: https://www.ontario.ca/page/coroners-inquests,” the Ministry’s statement noted.
Looking Ahead
The announcement of the Twiss inquest adds to the list of reviews currently underway in Ontario’s correctional system. While families often wait years for proceedings to begin, the government says inquests remain an essential tool for transparency and public trust.
For Mr. Twiss’s family, community members, and correctional staff, the inquest will provide an opportunity to understand what happened in December 2018 and what steps can be taken to prevent similar deaths in the future.
