period from 2006 to 2010, 264 deaths—or an average of 52 deaths per year—were classified as occupational accidents in British Columbia (BC Coroners Service, 2013b). The deaths occurred in a wide range of occupational categories coded by the BC Coroners Service, with the majority in the construction, forestry, and industrial categories (BC Coroners Service, 2013b). Because the coroner does not assume jurisdiction until a death is reported, not all fatality scenes are visited by the coroner; if a seriously injured worker is transported to hospital and dies later, the incident scene may therefore not have been examined. Between 2006 and 2010, the coroner did not attend the scene of accidental occupational deaths on an average of 30% of the time (BC Coroners Service, 2013b). If the coroner attends the accident scene and the cause of death is obvious upon the examination of the body or the cause of death can be determined by subsequent medical documentation and history, an autopsy may not be needed. Between 2006 and 2010, in accidental occupational deaths, autopsies were not conducted on an average of 35% of the time (BC Coroners Service, 2013b). Occupational accident investigators without medical or forensic medical knowledge may not thoroughly understand when an autopsy is or is not necessary, or be able to articulate to the coroner the reason why it may be required as part of the investigation. Coroners in British Columbia are not required to have medical education but obtain basic knowledge through training and experience of multiple death investigations. Coroners typically do not have any formal forensic education but rely on the forensic pathologist for this expertise. The forensic pathologist determines the cause of death for the coroner, who then completes the certification of death (Spitz, 2006). Although the forensic pathologist will document the injuries to the occupational accident investigator, the injuries themselves may be of more importance than the cause of death in understanding the incident. WorkSafeBC fatal and serious injury investigators indicated in a survey that 89% of investigators either never or seldom attended autopsies or discussed the scene circumstances with the forensic pathologist (WorkSafeBC, 2012). This is a crucial omission. Because injured workers may be taken from the scene of an occupational accident and die later in hospital, and the incident is not reported to the coroner until the death occurs, the coroner would not have had the opportunity to examine or understand the circumstances of the accident and may not have examined the body. As a result, the forensic pathologist receives only general details of the incident on the authorization for postmortem examination and is unable to provide detailed injury identification to WorkSafeBC investigators or describe any relationship between any injuries and what the worker was doing. The autopsy is not conducted in a vacuum: death is a functional event, not an anatomical event (Spitz, 2006). The cause of death is not always revealed by structural changes detected at autopsy. In addition, postmortem findings sometimes only exclude possible scenarios and do not provide a definitive answer. Only a detailed scene examination analyzed in conjunction with the autopsy findings and any toxicology will provide an accurate cause of death. Dr. Carol Lee, a forensic pathologist at the Vancouver General Hospital, believes that the scene findings and autopsy findings go hand-in-hand in piecing together what happened in an incident. The characteristics of injuries, such as location and dimensions, can provide information that is useful in scenario reconstructions. Measurements taken at autopsy can be correlated with instruments or structures at the scene. However, the forensic pathologist must receive direction as to what needs to be evaluated and/or measured and needs to understand the scene circumstances in order evaluate the findings (Dr. Carol Lee, personal communication, Original Article 196 www.journalforensicnursing.com Volume 9 • Number 4 • October–December 2013 Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited. October 22, 2012). Without an occupational accident investigations officer either in attendance or in consultation, the opportunity to obtain what may be crucial data for incident reconstruction may be lost. Having a forensic pathologist involved does not preclude the need to collaborate in the common goal of understanding the cause of death. If the coroner did not attend the scene or did not appreciate the significance of the intricacies of the work process in combination with the forensic evaluation of the various injuries and crucial information about scene circumstances is not conveyed to the forensic pathologist, no understanding of the injury and event and no system analysis will be provided for the occupational accident investigation. Furthermore, if the coroner determined that an autopsy was not necessary and the occupational accident investigator was depending on the forensic pathologist’s findings to help in determining the mechanism of injury, he or she may lose the opportunity to obtain crucial wound and injury information that should have been collected as part of the investigation at the scene. The coroner investigation