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