www.manitobacourts.mb.ca

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. Wood, Darren - October 9, 2025
  2. Samuel, Celine - August 29, 2025
  3. Ross, Aaron - July 18, 2025
  4. Collins, Jason Norman - March 12, 2025
  5. Koltusky, Timothy - January 28, 2025
  6. Monias, Adam and Richard, Max - December 5, 2024
  7. Ettawakapow, John George - November 7, 2024
  8. Gagnon, Patrick;  Bagot, Michael;  Fosseneuve, Michael;  Thompson, Sean; and Cochrane, Randy - October 23, 2024 
  9. Chommany, Viengxay - October 23, 2024 
  10. Brar, Jasbir - October 11, 2024
  11. Sutherland, Jordan - September 12, 2024
  12. Campbell, Steven - August 23, 2024
  13. Caron, Evan and Lacquette, Adrian - July 31, 2024
  14. Zygarliski, Amanda - July 15, 2024 
  15. Shworob, Adriel - June 28, 2024
  16. Jeffrey Tait - March 24, 2023
  17. David Norbert - October 28, 2022
  18. Chad Johnathan Williams - October 19, 2022
  19. Richard, Benjiman - August 3, 2022
  20. Kakish, Richard - July 9, 2021
  21. Saunders, William - May 20, 2021
  22. Sitar, Lewis - October 2, 2020
  23. LeBlanc, Taumas Justin  - May 15, 2020
  24. Spence, Russell- April 29, 2020
  25. Zong, Freeman - December 17, 2019
  26. Beaumont, Jean Paul - November 8, 2019
  27. Sefa, Haki and Dicesare, Mark - October 9, 2019
  28. Greene, Bradley Errol - June 11, 2019
  29. Taki, Ali Al - October 10, 2018
  30. Sampson, Devon and Flett, Dwayne Mervin - September 6, 2018
    volume 1
    volume 2
    Erratum
  31. Bell, Roy - August 8, 2018
  32. Daniels, Eric - July 3, 2018
  33. Muir, Lance - April 18, 2018
  34. R.D. - April 11, 2018
  35. Christopher Chastellaine - February 15, 2018
  36. Ronald Bobbie - June 16, 2017
  37. Michael Winsor - May 16, 2017
  38. Craig Vincent McDougall - May 9, 2017
  39. Cosmo Damiano Valente - April 21, 2017
              Erratum - April 26, 2017
     
  40. Tyler St. Paul - December 6 2016
  41. Gilbert Moise - Nov 4, 2016
  42. Michael Brian Langan - July 14, 2016
  43. David Durval Tavares and Sheldon Anthony McKay - June 15, 2016
  44. Craig Kucher - April 13, 2016
  45. Paul Duck - February 24, 2016
  46. Brian McPherson - February 12, 2016
  47. M.A.  December 30, 2015
  48. Heather Brenan - December 29, 2015
  49. Drianna Ross - December 22, 2015
  50. Demurs James, Throne Kirkness, Kayleigh Okemow - November 4, 2015
  51. Errabella Angel Harper - November 4, 2015
  52. Calvin Waylon McDougall - July 23, 2015
  53. James Livingston - June 26, 2015
  54. Frank Alexander - May 29, 2015
  55. Brian Lloyd Sinclair - December 12, 2014
  56. Jeffrey Ray Mallett - December 5, 2014
  57. Douglas Sanderson - June 5, 2014
  58. Robert Wood - May 29, 2014
  59. Jaylene Redhead - May 23, 2014
  60. Donald Ray Moose - May 21, 2014
  61. Ann Hickey - February 14, 2014
  62. Rudolph James Starr - November 27, 2013
  63. Wilfred Lesley Asham - October 17, 2012
  64. Nathan Michael Boryskavich - August 22, 2012
  65. C.J. and C.B. - July 3, 2012
  66. Ahmad Saleh-Azad - September 30, 2011
  67. Maurice Paul Thomas - July 20, 2011
  68. Cheryl Lynn Tom - July 7, 2011
  69. Andrew Szabo - June 17, 2011
  70. Shawn Jones, Raynald Gerling, Brian Palmquist - November 5, 2010
  71. Randy George Krasnesky - September 29, 2010
  72. Devon Chester Newson – December 21,2009
  73. Howard Glenn Fleury - December 4, 2009
  74. Russell Cook – December 1, 200
  75. Zunga Ramadan Bashir - July 20, 2009
  76. Darlene Rose Owens - May 11, 2009
  77. Alan Earle Rupert - April 27, 2009
  78. Grant Ryan Ermine - April 1, 2009
  79. Matthew Adam Joseph Dumas - December 9, 2008
  80. 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
  81. Tracia Owen - January 16, 2008
  82. Mitchell Adam Audy - October 12, 2007
  83. Sherrill Wilfred Forbister - August 24, 2007
  84. Paul Laurent Joubert - August 9, 2007
  85. Rachel Lori Wood - June 4, 2007
  86. Christopher John Holoka – May 16, 2007
  87. Dennis Robinson - March 26, 2007
    Appendix A to the Dennis Robinson Inquest Report
  88. John Erik Demery - December 22, 2006
  89. Melford William Nickoshie - December 11, 2006
  90. Peter Stevenson - October 30, 2006
  91. Keyanna Marie Snowdon - August 1, 2006
  92. Dennis St.Paul - July 19, 2006
  93. Sharon Joyce Horn - June 13, 2006
  94. Eric Clipping - April 26, 2006
    (available only in print from the Office of the Chief Medical Examiner)
  95. Anna Maciocha - March 6, 2006
  96. Calvin Sean Wood - November 28, 2005
  97. Ettie June Morris - September 12, 2005
  98. Glenn Fiddler - September 12, 2005
  99. Alan Nicolson - August 25, 2005
  100. Richard Franklin Lagimodiere - August 12, 2005
  101. Leon Herman Bighetty - August 5, 2005
  102. Laura Lee Draper and Arthur Randy Gill - July 14, 2005
  103. Donald Lorne Miles - January 27, 2005
    Appendix A to the Donald Lorne Miles Inquest Report
  104. Isobel Lathan - September 7, 2004
  105. Susan Capelia Redhead - July 22, 2004
  106. Henry Dueck - April 27, 2004
  107. Baby Collin Dorber Squire - March 29, 2004 
    Exhibit List for the Baby Collin Dorber Squire Inquest Report
  108. Lorna Joyce Ballantyne, Conway Wilfred Ballantyne, Baptiste Aaron Ballantyne - March 29, 2004
  109. Nadine Beaulieu - March 12, 2004
    (available only in print from the Office of the Chief Medical Examiner)
  110. Clayton Scott - February 2, 2004
  111. Abraham Hiebert - August 1, 2003
    Exhibit List for the Abraham Hiebert Inquest Report
  112. Joshua Harder - July 22, 2003
  113. Cory Moar - May 14, 2003
  114. Viola Contois - March 27, 2003
  115. Sophia Lynn Schmidt - February 7, 2003
  116. 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
  117. James Friesen and David Schroeder - October 31, 2002
  118. 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 9, 2025