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