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
- Roulette, Tyson - November 24, 2025
- Earnshaw, Lee - October 31, 2025
- Wood, Darren - October 9, 2025
- Samuel, Celine - August 29, 2025
- Ross, Aaron - July 18, 2025
- Collins, Jason Norman - March 12, 2025
- Koltusky, Timothy - January 28, 2025
- Monias, Adam and Richard, Max - December 5, 2024
- Ettawakapow, John George - November 7, 2024
- Gagnon, Patrick; Bagot, Michael; Fosseneuve, Michael; Thompson, Sean; and Cochrane, Randy - October 23, 2024
- Chommany, Viengxay - October 23, 2024
- Brar, Jasbir - October 11, 2024
- Sutherland, Jordan - September 12, 2024
- Campbell, Steven - August 23, 2024
- Caron, Evan and Lacquette, Adrian - July 31, 2024
- Zygarliski, Amanda - July 15, 2024
- Shworob, Adriel - June 28, 2024
- Jeffrey Tait - March 24, 2023
- David Norbert - October 28, 2022
- Chad Johnathan Williams - October 19, 2022
- Richard, Benjiman - August 3, 2022
- Kakish, Richard - July 9, 2021
- Saunders, William - May 20, 2021
- Sitar, Lewis - October 2, 2020
- LeBlanc, Taumas Justin - May 15, 2020
- Spence, Russell- April 29, 2020
- Zong, Freeman - December 17, 2019
- Beaumont, Jean Paul - November 8, 2019
- Sefa, Haki and Dicesare, Mark - October 9, 2019
- Greene, Bradley Errol - June 11, 2019
- Taki, Ali Al - October 10, 2018
- Sampson, Devon and Flett, Dwayne Mervin - September 6, 2018
volume 1
volume 2
Erratum - Bell, Roy - August 8, 2018
- Daniels, Eric - July 3, 2018
- Muir, Lance - April 18, 2018
- R.D. - April 11, 2018
- Christopher Chastellaine - February 15, 2018
- Ronald Bobbie - June 16, 2017
- Michael Winsor - May 16, 2017
- Craig Vincent McDougall - May 9, 2017
- Cosmo Damiano Valente - April 21, 2017
Erratum - April 26, 2017
- Tyler St. Paul - December 6 2016
- Gilbert Moise - Nov 4, 2016
- Michael Brian Langan - July 14, 2016
- David Durval Tavares and Sheldon Anthony McKay - June 15, 2016
- Craig Kucher - April 13, 2016
- Paul Duck - February 24, 2016
- Brian McPherson - February 12, 2016
- M.A. December 30, 2015
- Heather Brenan - December 29, 2015
- Drianna Ross - December 22, 2015
- Demurs James, Throne Kirkness, Kayleigh Okemow - November 4, 2015
- Errabella Angel Harper - November 4, 2015
- Calvin Waylon McDougall - July 23, 2015
- James Livingston - June 26, 2015
- Frank Alexander - May 29, 2015
- Brian Lloyd Sinclair - December 12, 2014
- Jeffrey Ray Mallett - December 5, 2014
- Douglas Sanderson - June 5, 2014
- Robert Wood - May 29, 2014
- Jaylene Redhead - May 23, 2014
- Donald Ray Moose - May 21, 2014
- Ann Hickey - February 14, 2014
- Rudolph James Starr - November 27, 2013
- Wilfred Lesley Asham - October 17, 2012
- Nathan Michael Boryskavich - August 22, 2012
- C.J. and C.B. - July 3, 2012
- Ahmad Saleh-Azad - September 30, 2011
- Maurice Paul Thomas - July 20, 2011
- Cheryl Lynn Tom - July 7, 2011
- Andrew Szabo - June 17, 2011
- Shawn Jones, Raynald Gerling, Brian Palmquist - November 5, 2010
- Randy George Krasnesky - September 29, 2010
- Devon Chester Newson – December 21,2009
- Howard Glenn Fleury - December 4, 2009
- Russell Cook – December 1, 200
- Zunga Ramadan Bashir - July 20, 2009
- Darlene Rose Owens - May 11, 2009
- Alan Earle Rupert - April 27, 2009
- Grant Ryan Ermine - April 1, 2009
- Matthew Adam Joseph Dumas - December 9, 2008
- 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 - Tracia Owen - January 16, 2008
- Mitchell Adam Audy - October 12, 2007
- Sherrill Wilfred Forbister - August 24, 2007
- Paul Laurent Joubert - August 9, 2007
- Rachel Lori Wood - June 4, 2007
- Christopher John Holoka – May 16, 2007
- Dennis Robinson - March 26, 2007
Appendix A to the Dennis Robinson Inquest Report - John Erik Demery - December 22, 2006
- Melford William Nickoshie - December 11, 2006
- Peter Stevenson - October 30, 2006
- Keyanna Marie Snowdon - August 1, 2006
- Dennis St.Paul - July 19, 2006
- Sharon Joyce Horn - June 13, 2006
- Eric Clipping - April 26, 2006
(available only in print from the Office of the Chief Medical Examiner) - Anna Maciocha - March 6, 2006
- Calvin Sean Wood - November 28, 2005
- Ettie June Morris - September 12, 2005
- Glenn Fiddler - September 12, 2005
- Alan Nicolson - August 25, 2005
- Richard Franklin Lagimodiere - August 12, 2005
- Leon Herman Bighetty - August 5, 2005
- Laura Lee Draper and Arthur Randy Gill - July 14, 2005
- Donald Lorne Miles - January 27, 2005
Appendix A to the Donald Lorne Miles Inquest Report - Isobel Lathan - September 7, 2004
- Susan Capelia Redhead - July 22, 2004
- Henry Dueck - April 27, 2004
- Baby Collin Dorber Squire - March 29, 2004
Exhibit List for the Baby Collin Dorber Squire Inquest Report - Lorna Joyce Ballantyne, Conway Wilfred Ballantyne, Baptiste Aaron Ballantyne - March 29, 2004
- Nadine Beaulieu - March 12, 2004
(available only in print from the Office of the Chief Medical Examiner) - Clayton Scott - February 2, 2004
- Abraham Hiebert - August 1, 2003
Exhibit List for the Abraham Hiebert Inquest Report - Joshua Harder - July 22, 2003
- Cory Moar - May 14, 2003
- Viola Contois - March 27, 2003
- Sophia Lynn Schmidt - February 7, 2003
- 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 - James Friesen and David Schroeder - October 31, 2002
- Doreen Leclair and Corrine McKeown - October 29, 2002
Table of Contents for the Doreen Leclair and Corrine McKeown Inquest Report
