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