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