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Inquest Reports

Under The Fatality Inquires Act, the Chief Medical Examiner may direct that an inquest be held into the death of a person. Inquests are presided over by judges of the Provincial Court of Manitoba. Following the inquest, the judge submits a report and may recommend changes in the programs, policies and practices of government that in his or her opinion would reduce the likelihood of a death in circumstances similar to those that resulted in the death that is the subject of the inquest.

Below is an index of the recent Inquest Reports issued by a judge of the Provincial Court. The date referenced is the date that the Inquest Report was publicly released.

Most of the Inquest Reports found below can be downloaded. If you wish to obtain a print copy of an Inquest Report found below or of an older Inquest Report, please contact the Office of the Chief Medical Examiner in Manitoba at 1-800-282-8069 or (204) 945-2088.

In 1985, in order to avoid duplicate investigations, the Chief Medical Examiner and the Ombudsman developed a protocol by which they agreed that if a death were the subject of an inquest, the role of the Ombudsman would be to follow up with the provincial government department, agency, board commission or municipality to which inquest recommendations were directed.

After an inquest report is received, the Ombudsman contacts each department or agency of government or a municipality to which a recommendation is directed to determine what action it is taking. After a satisfactory response to each recommendation has been received, a letter is sent to the Chief Judge of the Provincial Court advising of those responses.

Copies of the Ombudsman’s letter to the Chief Judge, along with the status of the department/agency’s response to the recommendations, are available at www.ombudsman.mb.ca.

Special Note:
The Report of the Manitoba Pediatric Cardiac Surgery Inquest: an Inquiry into Twelve Deaths at the Winnipeg Health Science Center, 1994 of Associate Chief Judge Murray Sinclair (as he then was) is available at www.pediatriccardiacinquest.mb.ca

 

  1. Taki, Ali Al - October 10, 2018
  2. Sampson, Devon and Flett, Dwayne Mervin - September 6, 2018
    volume 1
    volume 2
    Erratum
  3. Bell, Roy - August 8, 2018
  4. Daniels, Eric - July 3, 2018
  5. Muir, Lance - April 18, 2018
  6. R.D. - April 11, 2018
  7. Christopher Chastellaine - February 15, 2018
  8. Ronald Bobbie - June 16, 2017
  9. Michael Winsor - May 16, 2017
  10. Craig Vincent McDougall - May 9, 2017
  11. Cosmo Damiano Valente - April 21, 2017
              Erratum - April 26, 2017
     
  12. Tyler St. Paul - December 6 2016
  13. Gilbert Moise - Nov 4, 2016
  14. Michael Brian Langan - July 14, 2016
  15. David Durval Tavares and Sheldon Anthony McKay - June 15, 2016
  16. Craig Kucher - April 13, 2016
  17. Paul Duck - February 24, 2016
  18. Brian McPherson - February 12, 2016
  19. M.A.  December 30, 2015
  20. Heather Brenan - December 29, 2015
  21. Drianna Ross - December 22, 2015
  22. Demurs James, Throne Kirkness, Kayleigh Okemow - November 4, 2015
  23. Errabella Angel Harper - November 4, 2015
  24. Calvin Waylon McDougall - July 23, 2015
  25. James Livingston - June 26, 2015
  26. Frank Alexander - May 29, 2015
  27. Brian Lloyd Sinclair - December 12, 2014
  28. Jeffrey Ray Mallett - December 5, 2014
  29. Douglas Sanderson - June 5, 2014
  30. Robert Wood - May 29, 2014
  31. Jaylene Redhead - May 23, 2014
  32. Donald Ray Moose - May 21, 2014
  33. Ann Hickey - February 14, 2014
  34. Rudolph James Starr - November 27, 2013
  35. Wilfred Lesley Asham - October 17, 2012
  36. Nathan Michael Boryskavich - August 22, 2012
  37. C.J. and C.B. - July 3, 2012
  38. Ahmad Saleh-Azad - September 30, 2011
  39. Maurice Paul Thomas - July 20, 2011
  40. Cheryl Lynn Tom - July 7, 2011
  41. Andrew Szabo - June 17, 2011
  42. Shawn Jones, Raynald Gerling, Brian Palmquist - November 5, 2010
  43. Randy George Krasnesky - September 29, 2010
  44. Devon Chester Newson – December 21,2009
  45. Howard Glenn Fleury - December 4, 2009
  46. Russell Cook – December 1, 200
  47. Zunga Ramadan Bashir - July 20, 2009
  48. Darlene Rose Owens - May 11, 2009
  49. Alan Earle Rupert - April 27, 2009
  50. Grant Ryan Ermine - April 1, 2009
  51. Matthew Adam Joseph Dumas - December 9, 2008
  52. Steven Ryan Ewing – November 4, 2008
    Appendix A
    Appendix B
    Appendix C
    Appendix D
    Appendix E
    Appendix F
    Appendix G
    Appendix H
    Appendix I
    Appendix J
    Appendix K
    Appendix L
  53. Tracia Owen - January 16, 2008
  54. Mitchell Adam Audy - October 12, 2007
  55. Sherrill Wilfred Forbister - August 24, 2007
  56. Paul Laurent Joubert - August 9, 2007
  57. Rachel Lori Wood - June 4, 2007
  58. Christopher John Holoka – May 16, 2007
  59. Dennis Robinson - March 26, 2007
    Appendix A to the Dennis Robinson Inquest Report
  60. John Erik Demery - December 22, 2006
  61. Melford William Nickoshie - December 11, 2006
  62. Peter Stevenson - October 30, 2006
  63. Keyanna Marie Snowdon - August 1, 2006
  64. Dennis St.Paul - July 19, 2006
  65. Sharon Joyce Horn - June 13, 2006
  66. Eric Clipping - April 26, 2006
    (available only in print from the Office of the Chief Medical Examiner)
  67. Anna Maciocha - March 6, 2006
  68. Calvin Sean Wood - November 28, 2005
  69. Ettie June Morris - September 12, 2005
  70. Glenn Fiddler - September 12, 2005
  71. Alan Nicolson - August 25, 2005
  72. Richard Franklin Lagimodiere - August 12, 2005
  73. Leon Herman Bighetty - August 5, 2005
  74. Laura Lee Draper and Arthur Randy Gill - July 14, 2005
  75. Donald Lorne Miles - January 27, 2005
    Appendix A to the Donald Lorne Miles Inquest Report
  76. Isobel Lathan - September 7, 2004
  77. Susan Capelia Redhead - July 22, 2004
  78. Henry Dueck - April 27, 2004
  79. Baby Collin Dorber Squire - March 29, 2004 
    Exhibit List for the Baby Collin Dorber Squire Inquest Report
  80. Lorna Joyce Ballantyne, Conway Wilfred Ballantyne, Baptiste Aaron Ballantyne - March 29, 2004
  81. Nadine Beaulieu - March 12, 2004
    (available only in print from the Office of the Chief Medical Examiner)
  82. Clayton Scott - February 2, 2004
  83. Abraham Hiebert - August 1, 2003
    Exhibit List for the Abraham Hiebert Inquest Report
  84. Joshua Harder - July 22, 2003
  85. Cory Moar - May 14, 2003
  86. Viola Contois - March 27, 2003
  87. Sophia Lynn Schmidt - February 7, 2003
  88. Patrick Norman Redhead - January 16, 2003
    Exhibit List for the Patrick Norman Redhead Inquest Report
    Artwork of Patrick Norman Redhead referred to in the Inquest Report
  89. James Friesen and David Schroeder - October 31, 2002
  90. Doreen Leclair and Corrine McKeown - October 29, 2002
    Table of Contents for the Doreen Leclair and Corrine McKeown Inquest Report

Information on this page last updated on October 22, 2018