Coroners Thoroughly Investigating Deaths

"We all were like, oh, yeah, so that's what happens when  you don't send a coroner to [the] scene."

"Had someone from the coroners service attended, they would have spent enough time doing the scene assessment to realize that there was something else."

"It's not quite right." 

Sonya Schulz, former community coroner

 

"[We are concerned that the policy directive implemented in the Lower Mainland would mean] reduced attendance [at certain death scenes]." 

"We recognize the fiscal constraints imposed on BCCS [British Columbia Coroners Service] and are cognizant that efforts are needed to reduce expenditures."

"But we worry that reduced scene attendance will result in a lower quality of service to families during the most difficult time in their lives."

Field Coroners' group letter to regional director 

 

"[Coroners attend in person for] the majority of deaths that are reported; however in certain limited circumstances, a coroner may use their discretion to attend virtually or over the phone instead of in person."

"[These could include death scenes that are unsafe, in a care facility, or when there are] competing priorities on the coroner's availability and capacity [several deaths simultaneously]." 

B.C. Coroners Service

Former community coroner Sonya Schulz poses for a photograph outside The Heatley Block single-room occupancy building, in Vancouver, on Wednesday, Aug. 20, 2025. Photo: Darryl Dyck/The Canadian Press 

 

Informed speculation is that pressures facing the B.C. Coroners Service given the grim nature of the work may have led to the bungling of what is known as the Pham case. Former community coroner Sonya Schulz pointed to the Heatley Avenue apartment of Jimmy Van Chung Pham, a man with a criminal history, where dead bodies were found and the resident of the one-room dwelling was known for hoarding; insects and vermin would typically be attracted, a sign to an informed eye that all is not well. 

 

Settings such as this are so 'malodorous' that police themselves even while investigating crime scenes might choose to wait outside in  a car or in a hallway or lobby to avoid more direct contact, while a coroner on his/her own would investigate the premises. It was her informed opinion that the two other bodies would likely have been discovered, given signs including  an "odour of decomposition" that led other building residents to complain of, before the room resident's death.

 

Police had gone to a single-room occupancy building three years earlier in east Vancouver, where they found the body of Jimmy Van Chung Pham. Police failed to 'notice' the bodies of missing Indigenous teen, Noelle O'Soup (13 years old) along  with the body of a woman named Elma Enan. It was only months afterward that their decomposing  remains were located in that tiny room occupied by an "extreme hoarder".

 

Noelle (Elli) O’Soup In a photo taken not long before she disappeared in May 2021 at age 13. Family photo supplied by Michelle Munch

 

The original attending police officer now faces a neglect-of-duty investigation by the Office of the Police Complaint commissioner. A second investigator, the community coroner (field coroner), tasked to investigate Pham's death scene, also failed to notice the two bodies. However, the coroner was not physically present at the scene; he conducted his investigation by telephone. He attended the scene 'remotely' by speaking to the police officer who was present, by telephone. 

 

Field coroners receive $32 an hour for their professional services and receive no recompense while awaiting a call. This, along with the years of neglect from the service with its low regard for their important duties, financial restrictions on the service, all contributed to the poor investigative mode in this particular case, sufficiently unique to have been widely discussed among area field coroners, all of whom agree this would never have occurred had a coroner been dispatched directly to the scene.

 

'Fiscal prudence' had led to the unfortunate downgrading of the vital professional service: "in response to a government-wide request for fiscal prudence". The resulting limitations on "scene attendance in certain circumstances" have since been restored, the Coroners Service asserted. Coroners now appear in person at such death scenes. Morale has been damaged, according to current and former community British Columbia coroners, where low pay, and on-call work spurred a high turnover of experienced investigators, their calls for improved working conditions ignored.   

"Their job is to determine the manner of death and the cause of death and I simply do not see how that is possible if they don't also have first-hand knowledge about the circumstances in which the person was found, and they can only obtain that, in my view, from attending the scene."

"[It was unclear why the service failed to go to the apartment of Pham, whom the Union of B.C. Indian Chiefs named a] known predator and sex offender."

Sue Brown, lawyer with advocacy group Justice for Girls 

Still captured from video