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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. Matthew Adam Joseph Dumas - December 9, 2008
  2. 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
  3. Tracia Owen - January 16, 2008
  4. Mitchell Adam Audy - October 12, 2007
  5. Sherrill Wilfred Forbister - August 24, 2007
  6. Paul Laurent Joubert - August 9, 2007
  7. Rachel Lori Wood - June 4, 2007
  8. Christopher John Holoka – May 16, 2007
  9. Dennis Robinson - March 26, 2007
    Appendix A to the Dennis Robinson Inquest Report
  10. John Erik Demery - December 22, 2006
  11. Melford William Nickoshie - December 11, 2006
  12. Peter Stevenson - October 30, 2006
  13. Keyanna Marie Snowdon - August 1, 2006
  14. Dennis St.Paul - July 19, 2006
  15. Sharon Joyce Horn - June 13, 2006
  16. Eric Clipping - April 26, 2006
    (available only in print from the Office of the Chief Medical Examiner)
  17. Anna Maciocha - March 6, 2006
  18. Calvin Sean Wood - November 28, 2005
  19. Ettie June Morris - September 12, 2005
  20. Glenn Fiddler - September 12, 2005
  21. Alan Nicolson - August 25, 2005
  22. Richard Franklin Lagimodiere - August 12, 2005
  23. Leon Herman Bighetty - August 5, 2005
  24. Laura Lee Draper and Arthur Randy Gill - July 14, 2005
  25. Donald Lorne Miles - January 27, 2005
    Appendix A to the Donald Lorne Miles Inquest Report
  26. Isobel Lathan - September 7, 2004
  27. Susan Capelia Redhead - July 22, 2004
  28. Henry Dueck - April 27, 2004
  29. Baby Collin Dorber Squire - March 29, 2004
    Exhibit List for the Baby Collin Dorber Squire Inquest Report
  30. Lorna Joyce Ballantyne, Conway Wilfred Ballantyne, Baptiste Aaron Ballantyne - March 29, 2004
  31. Nadine Beaulieu - March 12, 2004
    (available only in print from the Office of the Chief Medical Examiner)
  32. Clayton Scott - February 2, 2004
  33. Abraham Hiebert - August 1, 2003
    Exhibit List for the Abraham Hiebert Inquest Report
  34. Joshua Harder - July 22, 2003
  35. Cory Moar - May 14, 2003
  36. Voila Contois - March 27, 2003
  37. Sophia Lynn Schmidt - February 7, 2003
  38. 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
  39. James Friesen and David Schroeder - October 31, 2002
  40. Doreen Leclair and Corrine McKeown - October 29, 2002
    Table of Contents for the Doreen Leclair and Corrine McKeown Inquest Report

 

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