Timely coroners' reports and a need for serious incident analysis in homes that care for adults with intellectual disabilities are two of the key topics identified in the second volume of the 2021 Auditor’s report.

The Provincial Auditor is an independent role of the Legislative Assembly of Saskatchewan which provides the public with a non-partisan assessment of the government’s use of resources.


Provincial Auditor Tara Clemett looked at whether timely, accurate investigations into unexpected or unexplained deaths were being adequately completed by the Saskatchewan Coroners Service.

Eight recommendations were made to the Ministry of Justice and Attorney General in the report, after it was determined the coroners' service is not always completing and reporting findings in a timely fashion.

“We found two coroner investigations had final coroners’ reports signed 150 and 169 days after receiving final autopsy reports, which means families waited more than five months for their coroners’ report and subsequent closure,” the report reads. “At June 2021, there were 20 coroner investigations outstanding for more than six months.”

The audit also found the coroners' service does not have identified timelines for reporting the results of investigations to families.

The coroners’ service makes recommendations to agencies to prevent future deaths and improve safety. The audit found the coroners’ office does not follow up with those agencies to ensure recommendations are being implemented.

The number of death investigations conducted has trended upward over the past four years, as has spending on the coroners’ service, the report states.


The Auditors report also found that the Ministry of Social Services needs to more effectively monitor group and private care homes for adults with intellectual disabilities.

“Continuously inspecting and analyzing reported serious incidents helps confirm homes provide safe and quality care for clients,” Clemett said. “Having a central system to track key information about homes would also aid in better monitoring, as it would allow the Ministry to readily see summarized data about homes and identify persistent issues that may impact client care.”

Care home residents referred to in the report as clients, are able to create plans based on their goals and dreams in partnership with home operators. The Auditor found the Ministry does not monitor the quality or fulfillment of these plans.

The Ministry also does not analyze incidents to identify ongoing issues, the auditor found.

“In 2020–21, group homes reported 748 serious incidents and approved private service homes reported 111 serious incidents. Furthermore, the Ministry does not monitor whether homes implement recommendations based on serious incident investigations.”


Clemett’s audit found the government effectively delivered financial support programs while safeguarding public resources.

Clemett said rolling out such programs can create issues for resource management, but the province was able to effectively manage the need for such programs quickly.


In this volume of the Auditors report, Clemett followed up on recommendations made in previous reports regarding increasing school instruction time.

The 2021 report said the Ministry of Education has made “limited progress” in improving school instruction time since those recommendations were tabled in 2009.

In May of 2021, the Ministry introduced a declaration process to monitor divisions’ compliance with required school instruction time. Not all school divisions are meeting the requirements, with 15 of 27 divisions unable to meet the hours required. One division did not respond.

“The Ministry has taken limited action to follow up with those school divisions not in compliance,” Clemetts report said. “It needs to individually follow up with school divisions to understand how they are meeting or not meeting minimum instruction hour requirements for core subjects and develop collaborative action plans to meet them.”

Ninety-five to 100 instruction hours are required for core subjects like math and English.


Clemett reported that the Saskatchewan Gaming Corporation shows some “vulnerabilities” concerning the prevention of cyberattacks which could impact IT systems it uses to deliver casino games. The report said reasonably good processes are in place.

According to the report, cybercrime costs Canadians roughly $3 billion in economic losses annually. The risk of monetary loss would impact supports, programs and services funded in Saskatchewan.

“While SaskGaming identified some cybersecurity risks, it did not analyze information from its ongoing security assessments to set effective action plans to address all significant cybersecurity risks.”