The Office of the Chief Coroner conducted the Drowning Review, and presents our findings and recommendations which we and the experts that assisted us believe, will significantly reduce the number of drowning deaths in Ontario and in Canada if implemented in the years to come. [...] A The noted sections of the Coroners Act were perception had developed in the Office of the used to make the decision to proceed with the Chief Coroner that there was a surge in Drowning Death Review. [...] Where the coroner determines that an The following will provide an in-depth overview inquest is unnecessary, the coroner shall of the data and the recommendations forthwith transmit to the Chief Coroner a developed in this review. [...] Bert Lauwers is the similar to those of the death that was the Deputy Chief Coroner of Investigations and was subject of the coroner's investigation. [...] He recently completed of the public, if the Chief Coroner the Edine IIunga Inquest which examined the reasonably believes that it is necessary in drowning of a child in a public pool, including the interests of public safety to do so.