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