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Inquest Reports
Under the Fatality Inquiries Act, the chief medical examiner may direct that an inquest be held into the death of a person. Inquests are presided over by provincial court judges. 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 similar circumstances.
Inquest reports are published on the Manitoba Courts website.
Since 1985, Manitoba Ombudsman has been responsible by way of an agreement with the chief medical examiner for following up with the provincial government department, agency, board, commission or municipality to which inquest recommendations are directed, to determine what action has been taken.
In 2008, Manitoba Ombudsman began making final reports with responses to the recommendations publicly available. For cases where the ombudsman review is complete, a final report is available below.
Reports are available in alternate formats upon request.
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Adriel Shworob – 2024-10-01
On March 10, 2020, Winnipeg Police Services attended Adriel Shworob’s residence following a series of 911 calls from his home and neighbours. After an unremarkable evening at home, Adriel attacked his father and his father’s spouse with a knife while they slept. Upon arrival, police found Adriel’s father lying outside on the ground with Adrial on top of him. Officers made efforts to de-escalate the situation. Eventually, an officer deployed a taser three times. Unfortunately, the taser did not have the desired effect and the attack on Adriel’s father continued. The officer concluded they had no choice but to use their firearm. The inquest judge noted in this case, tasers were ineffective and officers were left without a feasible intermediate weapon. The judge found the police response was appropriate in the circumstances. The judge made two recommendations related to studying and considering intermediate weapons available to general patrol officers. The inquest report was released on June 28, 2024.
Provincial Court of Manitoba Inquest Report - Shworob, Adriel - June 28, 2024
Manitoba Ombudsman Recommendation Monitoring Report: Pending
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Amanda Zygarliski – 2024-10-01
At the time of her death, Amanda Zygarliski resided at Women’s Correctional Centre. On May 15, 2021, Ms. Zygarliski ate a meal in her video-monitored secure cell where she was housed alone. Shortly after beginning her meal, she began showing signs of choking. After waving at the security camera and pushing an intercom button in her cell, she fell to the ground and stopped moving. Approximately 35 minutes later, officers entered her cell and attempted resuscitation. Earlier that day, Ms. Zygarliski was supposed to be released to a designated community agency. However, when representatives arrived, they did not have the appropriate paperwork with them. Women’s Correctional Centre turned the representatives away, telling them to return with the appropriate paperwork. The inquest judge made three findings and two recommendations to prevent a similar death. The inquest report was released July 15, 2024.
Provincial Court of Manitoba Inquest Report - Zygarliski, Amanda - July 15, 2024
Manitoba Ombudsman Recommendation Monitoring Report: Pending
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Evan Caron & Adrian Laquette – 2024-10-01
A single inquest was held with respect to the deaths of Adrian Lacquette and Evan Caron. Mr. Lacquette and Mr. Caron were both Indigenous males killed by Winnipeg Police Service (WPS) officers.
On September 13, 2017, members of the WPS investigated several reported incidents involving a suspect with a gun. An altercation occurred when WPS officers confronted Adrian Lacquette, the suspect, resulting in Mr. Lacquette sustaining multiple gunshot wounds. He was transported to the Health Sciences Centre (HSC), where he was pronounced deceased.
On September 23, 2017, the WPS responded to calls of a possible stabbing at a residence. When an officer gained entry to the front door, Evan Caron, the suspect, stabbed the officer in the arm. The officer fired multiple rounds with his firearm at Mr. Caron, who was transported to HSC and pronounced deceased.
The inquest judge made two recommendations. The recommendations relate to calling single inquests into multiple deaths, and funding for legal counsel for family representatives in mandatory inquests. The inquest report was released on July 31, 2024.
Provincial Court of Manitoba Inquest Report - Caron, Evan and Lacquette, Adrian - July 31, 2024
Manitoba Ombudsman Recommendation Monitoring Report: Pending
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Steven Campbell 2024-10-01
On November 21, 2015, a Royal Canadian Mounted Police (RCMP) constable saw Steven Campbell driving his Jeep Cherokee in Thompson, Manitoba. The officer decided the driver was possibly impaired and decided to follow the Jeep, intending to stop it. Following a pursuit, the vehicles collided. Mr. Campbell tried to escape by driving his vehicle at the officer. The officer shot and killed Mr. Campbell. The officer was charged criminally in relation to the shooting death and in relation to his driving just before the shooting. The inquest report notes the tragic event followed actions that were unwise, unjustified and, insofar as the officer’s driving was concerned, illegal. In addition, the officer’s actions were contrary to their training. The officer left their employment and served the imposed sentence from the criminal trial. The inquest judge did not issue recommendations. The inquest report was released on August 23, 2024.
Provincial Court of Manitoba Inquest Report - Campbell, Steven - August 23, 2024
Manitoba Ombudsman Recommendation Monitoring Report: No recommendations. Review completed September 25, 2024.
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Jordan Sutherland 2024-10-01
Jordan Sutherland was a 26-year-old Indigenous man, only a few weeks shy of his 27th birthday. Mr. Sutherland died while serving a custodial sentence at Milner Ridge Correctional Centre. Shortly after midnight on June 24, 2020, an officer found Mr. Sutherland hanging in his cell. The incident occurred between the usual rounds officers conduct throughout the night. The inquest judge made eight recommendations to prevent a similar death. The recommendations focus on increasing psychiatric, psychological, and mental health supports, and staff training. The inquest report was released on September 12, 2024.
Provincial Court of Manitoba Inquest Report - Sutherland, Jordan - September 12, 2024
Manitoba Ombudsman Recommendation Monitoring Report: Pending
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Jeffrey Tait – 2023-05-02
At the time of his death, Jeffrey Tait was an inmate at Headingly Correctional Centre. On January 29, 2019, Mr. Tait was found in his cell unresponsive with a piece of fabric wrapped around his neck. The inquest report details Mr. Tait’s mental wellness challenges in the weeks leading up to his death. On the day of his death, Mr. Tait’s request to smudge outdoors was denied due to the cold winter temperatures. Later that day, camera footage from his cell showed Mr. Tait leaning against the wall with fabric around his neck and falling out of view of the camera. Two security rounds were done but officers did not notice Mr. Tait was unresponsive. Mr. Tait was found less than 2 hours after his last perceptible movement. Resuscitation efforts were unsuccessful. At the time of his death, Mr. Tait was 31 years old. The inquest judge made 7 recommendations. Date of inquest report – March 21, 2023. Status of review – pending.
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2.10 MB
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Benjamin Richard – 2022-12-23
On April 2, 2019, three Manitoba First Nation Police Service Officers attended a residence in Long Plain First Nation in response to concerns about Benjamin Richard behaving aggressively and discharging a firearm in his mother’s home. Mr. Richard discharged his firearm in the direction of an officer. Two constables returned fire resulting in Mr. Richard’s death. In the years before his death, Mr. Richard suffered traumatic losses of his father, cousin, and uncle. According to his family, he felt these losses deeply and turned to drugs and alcohol to cope. His family witnessed changes in his personality, behaviour and mental wellness leading up to and including the day of his passing. At the time of his death, Mr. Richard was twenty-three years old. Given the circumstances, the inquest judge declined to make formal recommendations to the Manitoba First Nations Police Service. There were also no recommendations made to a provincial department or agency. As such, there will be no final report by our office. The inquest report was released on July 27, 2022. Status of review – completed September 26, 2022.
richardbenjimaninquestjuly272022-final-inquest-report-en.pdfDownload
742.49 KB
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Chad Williams – 2022-12-23
On January 11, 2019, Winnipeg Police Services issued a ‘Be on the Lookout’ for Chad Williams related to a domestic assault involving a weapon. Police constables then engaged in a foot pursuit with Mr. Williams who was found to be carrying a hatchet. Mr. Williams was not responding to police commands to drop the hatchet. Attempts to immobilize him with a taser were unsuccessful. When Mr. Williams made a motion as if to throw the hatchet at an officer, three officers discharged their firearms. Mr. Williams underwent several surgeries after being hit by gunshots, but died from his injuries on January 12, 2019. The facts presented during the hearing established that his actions and response to police was influenced by the drugs in his system, including methamphetamine. The level of force used by officers to control and contain the threat posed by Mr. Williams was consistent with their training and appropriate in the circumstances. At the time of this death, Mr. Williams was twenty-six years old. Given the circumstances, the presiding judge made no recommendations in the inquest. There will be no final report issued by our office because there were no recommendations made to provincial departments or agencies. Date of inquest report - October 14, 2022. Status of review - completed November 8, 2022.
williamschadinquestreportoct142022restricteduntiloct192022fredericksonpj-3-en.pdfDownload
587.24 KB
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David Norbert – 2022-12-23
On April 16, 2019, David Norbert was arrested by Winnipeg Police Service officers on allegations he assaulted, injured and threatened his ex-roommate earlier that day. Mr. Norbert was detained in a Winnipeg Police Services holding cell pending his release or transport to the Winnipeg Remand Centre. Within minutes after he was informed of the decision to remand him into custody, he was discovered hanging by his shirt from a ventilation grate in the ceiling. Despite EMS attending, attempts at resuscitation were unsuccessful. At the time of his death, Mr. Norbert was 56 years old. Based on a review of the circumstances, including changes made to the ventilation grates in the holding cells, the presiding judge made no recommendations in the inquest report. There will be no final report issued by our office because there were no recommendations made to provincial departments or agencies. Date of inquest report - October 25, 2022. Status of review - completed November 8, 2022.
norbertdavidinquestoctober252022thompsonpj-3-en.pdfDownload
628.60 KB
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Richard Kakish – 2022-07-20
Link to inquest report
Richard Kakish was arrested by members of the Winnipeg Police Service on August 9, 2017. Force was used during his arrest and during processing at a police station. Following his arrest, he was transported to Seven Oaks General Hospital for medical treatment and subsequently admitted to the Winnipeg Remand Centre. On August 11, 2017, while at the Winnipeg Remand Centre, his medical condition deteriorated and he was transported to Health Sciences Centre. Internal bleeding was discovered during surgery due to a laceration of his spleen. The bleeding was stopped but Mr. Kakish's condition failed to improve and he was removed from life-support on August 13, 2017. Date of inquest report – July 6, 2021. Status of review – pending.
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Jean-Paul Beaumont – 2022-03-25
Link to inquest report.
Jean-Paul Beaumont was found unresponsive by fellow inmates on October 14, 2012 at Brandon Correctional Institution. In the hours leading up to the last time he was seen alive, other inmates saw him ingesting morphine pills and methamphetamine. His cause of death was determined to be morphine overdose. At the time of his death, Mr. Beaumont was 39 years old. Date of inquest report – November 4, 2019. Status of review – Completed July 11, 2023.
jpbeaumont-final-report-en.pdfDownload
193.54 KB
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William Saunders – 2021-05-21
Link to inquest report
William Saunders was being transported from the Lundar RCMP Detachment to Winnipeg Remand Centre by an RCMP officer on November 14, 2017. During the transport, the lone officer let Mr. Saunders out to relieve himself on the side of the highway. Mr. Saunders attacked the officer, and a struggle ensured, during which Mr. Saunders got shot in the shoulder. Eventually Mr. Saunders overcame the officer and drove away in the van. Later that evening RCMP located the van and started pursuit. The van went off the road and got stuck in the ditch. The RCMP Emergency Response Team attended, and Mr. Saunders was shot at the scene. Despite resuscitation efforts, Mr. Saunders could not be revived, and he was pronounced deceased. The RCMP is a federal organization and the inquest judge does not have jurisdiction to make recommendations on RCMP policy regarding transportation of prisoners. The inquest served as a fact-finding exercise to identify problems or deficiencies that may have led to Mr. Saunder’s death without making recommendations. Upon testifying at the inquest, RCMP advised that amendments were made to the Prisoner Escort Policy to reduce the likelihood of deaths in similar circumstances.
Since there were no recommendations made to provincial department or agencies, no follow up was required by our office and there will be no final report. The inquest report was released on May 21, 2021. Status of review – completed May 26, 2021.
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Lewis Sitar – 2021-04-27
Link to inquest report
Lewis Sitar was a sentenced prisoner in Stony Mountain Institution. On February 20, 2017 at 10:25 p.m. he was found unresponsive in his cell by correctional officers. He was taken to hospital, where he remained until he was pronounced dead on March 3, 2017. An autopsy was performed and the cause of death was blunt head trauma and the manner of death was homicide. A criminal investigation was conducted by the R.C.M.P. and two inmates were charged with second degree murder in relation to Mr. Sitar’s death. As Stony Mountain Institution is a federally run correctional facility, the Provincial Court Judge was without jurisdiction to make recommendations. The inquest served as a fact-finding exercise to identify problems or deficiencies that may have led to Mr. Sitar’s death without making recommendations. There were no recommendations made to provincial departments or agencies, therefore there was no follow up required by our office, and no final report. Date of inquest report is September 29, 2020. Manitoba Ombudsman received notification of the inquest report on January 6, 2021. Status of review – completed April 27, 2021.
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Russell Andrew Spence – 2020-06-19
Link to inquest report
Russell Spence was the subject of a well-being call made to Winnipeg Police Services at the end of the day on October 11, 2016 at his request. On their arrival, police arrested Mr. Spence and charged him with two counts of possessing a weapon. He was transported to the Winnipeg Police Headquarters and later transferred to the Remand Centre. Throughout this process he exhibited signs of being under the influence of drugs, and he indicated that he had consumed methamphetamine and alcohol earlier in the day. At the Remand Centre, Mr. Spence was directed into the shower and search room, where he became involved in a physical struggle with guards. During this time he was reportedly struck in the torso multiple times, had a spit mask applied, and at least one officer was on top of Mr. Spence’s upper back/heart region. Four minutes after this struggle began, he suddenly became unresponsive. Resuscitation efforts were unsuccessful at the scene and at the Health Sciences Centre, where Mr. Spence was declared deceased on October 12, 2016. Autopsy results showed a high level of methamphetamine in Mr. Spence’s blood, from which toxic effects would be expected, as well as an increased risk due to a slightly enlarged heart and the detrimental effects of the physical altercation. Date of inquest report is April 24, 2020. Status of review – pending.
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Taumas Justin LeBlanc – 2020-05-15
Link to inquest report
Taumas Justin LeBlanc came to his death in the early hours of February 13, 2017. Late in the evening of February 12, 2017, the father of Taumas LeBlanc called 911 requesting help to remove his intoxicated son from his home. Although not violent, he was afraid of his son. Winnipeg Police Services attended the home and Taumas’ behaviour quickly escalated and he became combative. Based on the behaviours Taumas was exhibiting, the officers suspected a medical emergency and a request was made for Winnipeg Fire Paramedic Services to attend and assist. When being removed from the home, Taumas stopped breathing. CPR was performed and Taumas was transported to Seven Oaks Hospital where he was pronounced deceased. The inquest judge concluded that police and paramedics recognized Taumas’ behaviour as signs of excited delirium, which puts an individual medically at-risk. When combined with other underlying health conditions as identified by the autopsy, it was determined that nothing the police or paramedics did contributed to increasing his risk. Given the evidence and the court’s findings and conclusion, no recommendations were made. The inquest report was released on May 15, 2020. Status of review: completed December 3, 2020. As there were no recommendation for the ombudsman to monitor, we did not issue a final report to the provincial chief judge.
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Freeman Thomas Gustave Zong – 2020-03-23
Link to inquest report
Freeman Zong was taken into custody by Dauphin RCMP officers on July 11, 2016, after the RCMP received reports that Mr. Zong had discharged a firearm and was threatening self-harm. After a hospital visit, he was admitted to the Dauphin Correctional Institution (DCI) and was assessed by the admitting officer as a medium suicide risk. On July 14, 2016, after another hospital visit, Mr. Zong committed suicide in the DCI washroom. The cause of death was determined to be asphyxiation by hanging. Date of inquest report is December 11, 2019 (released on December 17, 2019). Status of review – completed June 13, 2024.
2024-06-13_MO-00605_-_2019-0622_Final_Report_-_Freeman_Zong_Inquest.pdfDownload
300 KB
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Bradley Errol Greene – 2020-02-04
Link to inquest report
Bradley Errol Greene was arrested and admitted to the Winnipeg Remand Centre on March 12, 2016. He stated to the nurse that he suffered from epilepsy and took medication, which he last took that morning. There was no indication that he had been administered the required medication at the Winnipeg Remand Centre and he suffered a seizure during discharge on March 13, 2016. He was taken by ambulance to Health Sciences Centre. Approximately 7 weeks later, on April 30, 2016, Mr. Greene was again admitted to the Winnipeg Remand Centre. He again advised that he suffered from epilepsy and took medication and that his last seizure was when he was incarcerated two months prior. The following day, on May 1, 2016, Mr. Greene suffered two seizures, and each time he was restrained. Following the second seizure he became unresponsive, resuscitative efforts commenced, and he was transported to the Health Sciences Centre. His pulse was ultimately restored but he remained comatose and died later that evening. He received no seizure medication while held at the Winnipeg Remand Centre. Date of inquest report is June 6, 2019; Status of review – pending.
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Haki Sefa and Mark DiCesare – 2020-02-04
Link to inquest report
On September 20, 2015, Haki Sefa was the subject of a well-being check due to concerned family members. Mr. Sefa was not located at his home, nor did he answer his cell phone when officers attempted to contact him. His phone was “pinged” multiple times, without success in locating Mr. Sefa. Eventually it was learned by officers that Mr. Sefa had purchased a firearm and intended to kill himself and another person with which he had a grievance. Mr. Sefa’s phone was pinged again and he was located driving a white van. Mr. Sefa led officers on a lengthy low speed pursuit, eventually being pinned to a stop by members of the Winnipeg Police Service’s Tactical Team, north of Winnipeg. Shortly after, officers observed Mr. Sefa point a silver handgun at one of their members and he was shot dead by police.
On November 6, 2015, Mr. DiCesare drove past a police officer at a slow rate of speed and pointed a firearm at her, before driving away erratically and at a high rate of speed. Eventually, Mr. DiCesare was located, still driving his vehicle, where he was pursued by multiple members of the Winnipeg Police Service. Eventually, police managed to stop the vehicle in a field, where a standoff occurred. Mr. DiCesare entered and exited his vehicle expressing suicidal ideation and pointing his firearm at himself. Eventually, while apologizing to WPS members for forcing them to shoot him, he lowered his firearm, which was believed to be an Uzi sub-machine gun, so that it was pointing at WPS members. He was shot dead by police. The firearm was later examined and determined to be an imitation or replica firearm.
Both deaths were determined to be “suicide by cop”. Date of inquest report is October 9, 2019; Status of review – completed July 28, 2023.
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173 KB
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R.D. – 2019-02-04
Link to inquest report
R.D. was found hanging in her cell at Brandon Correctional Center on September 28, 2013 and succumbed to her injuries on October 2, 2013. R.D. was 16 years of age at the time of her death by suicide. Date of inquest report – April 6, 2018; Status of review – completed June 12, 2020.
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202.52 KB
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Eric Daniels – 2018-11-07
Link to inquest report
Eric Daniels came to his death on March 6, 2010, in Winnipeg, Manitoba. On that day, he advanced towards two members of the Winnipeg Police Service (WPS), while holding up a machete in a threatening manner. He ignored the verbal commands from the WPS officers to drop the machete and as he continued advancing towards the officers, they drew their pistols and fired at Mr. Daniels, hitting him and causing his death. The inquest judge concluded that, nothing could have been done by the WPS officers to change the outcome of the matter. Given the evidence and the court’s findings and conclusion, no recommendations were made. Status of review – completed August 20, 2018. As there were no recommendations for the ombudsman to monitor, we did not issue a final report to the provincial chief judge. We notified the WPS of our receipt of the inquest report and closed our file.
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726.65 KB
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Lance Muir – 2018-11-07
Link to inquest report
Lance Muir came to his death on May 9, 2010, in Winnipeg, Manitoba. On that day, he was the driver of a vehicle that accelerated rapidly at a member of the Winnipeg Police Service (WPS) who stopped the vehicle by discharging his firearm, causing Mr. Muir’s death. The inquest judge concluded that, nothing could have been done by the WPS officer to change the outcome of the matter. Given the evidence and the court’s findings and conclusion, no recommendations were made. Status of review – completed May 14, 2018. As there were no recommendations for the ombudsman to monitor, we did not issue a final report to the provincial chief judge. We notified the WPS of our receipt of the inquest report and closed our file.
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622.57 KB
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Roy Thomas Bell – 2018-11-07
Link to inquest report
Roy Bell came to his death on December 17, 2007, in Winnipeg, Manitoba. On that day, he advanced towards two members of the Winnipeg Police Service (WPS), wielding a baseball bat and ignoring verbal commands from the officers. Consequently, the officers discharged a taser and a firearm and Mr. Bell died because of gunshot wounds from the discharged firearm. The inquest judge concluded that nothing could have been done by the WPS officers to change the outcome of the matter. Given the evidence and the court’s findings and conclusion, no recommendations were made. Status of review – completed October 19, 2018. As there were no recommendations for the ombudsman to monitor, we did not issue a final report to the provincial chief judge. We notified the WPS of our receipt of the inquest report and closed our file.
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728.80 KB
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Ali Al Taki – 2018-11-05
Link to inquest report
Ali Al Taki fell and struck his head after being pushed by another patient at the Selkirk Mental Health Centre. While receiving treatment for this injury at Health Sciences Centre, he contracted pneumonia due to his immobility and died on June 24, 2016. Status of review – completed November 5, 2018. As there were no recommendations for the ombudsman to monitor, we did not issue a final report to the provincial chief judge. We notified Manitoba Health Seniors and Active Living of our receipt of the inquest report and closed our file.
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800.70 KB
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Devon Sampson and Dwayne Mervin Flett – 2018-11-05
Link to inquest report: volume 1, volume 2 and erratum
Devon Sampson came to his death on November 23, 2013 at Stony Mountain Institution, in the Province of Manitoba. Dwayne Mervin Flett came to his death on April 15, 2015 at Stony Mountain Institution, in the Province of Manitoba. Both caused their own deaths by suicide by hanging. Status of review – completed November 2, 2018. Inquest pertains to Stony Mountain Institution which falls outside provincial jurisdiction. No final report.
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Christopher Chastellaine – 2018-03-06
Link to inquest report
Christopher Chastellaine was arrested by the Winnipeg Police Service on May 22, 2014. While in custody, he was involved in an altercation involving six officers and subsequently lost consciousness. It was later determined that he suffered irreparable brain damage after his heart stopped and he stopped breathing. Mr. Chastellaine died on May 26, 2014 at the age of 40. Date of inquest report is February 12, 2018. Status of review -- completed February 14, 2019.
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2.68 MB
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Michael Winsor – 2017-07-13
Link to inquest report
Michael Winsor came to his death at 22 years of age on September 10, 2013 in the Health Sciences Centre, PsycHealth Unit, where he had just been admitted. He caused his own death by strangulation. Date of inquest report – May 16, 2017. Status of review – completed June 14, 2018.
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1.21 MB
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Ronald Bobbie – 2017-07-13
Link to inquest report
On September 26, 2014, Ronald Bobbie was pulled from the Red River just north of the Redwood Bridge in Winnipeg, Manitoba by Winnipeg Fire Paramedic Services. CPR was commenced and he was taken to St. Boniface Hospital, but he could not be revived; cause of death was drowning. At the time of his death, Mr. Bobbie, 59-years-old, was absent without leave from the Selkirk Mental Health Centre. Date of inquest report – June 13, 2017. Status of review – completed July 20, 2018.
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225.29 KB
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Craig Vincent McDougall – 2017-05-09
Link to inquest report
Craig Vincent McDougall came to his death at 26 years of age on August 2, 2008 in the front yard of 788 Simcoe Street in Winnipeg, where he was shot by Winnipeg Police. Date of inquest report – May 9, 2017. Status of review – completed August 8, 2018.
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4.19 MB
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Tyler Joseph St. Paul – 2016-12-06
Link to inquest report
Tyler Joseph St. Paul died on May 16, 2011 as a result of a punctured lung from being beaten by fellow gang members while in custody at Milner Ridge Correctional Centre. Date of inquest report – December 6, 2016. Status of review – completed August 15, 2017.
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881.15 KB
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Craig Kucher – 2016-04-07
Link to inquest report
Craig Kucher died in Brandon, Manitoba on June 18, 2012 after sustaining injuries as a result of a train accident. He was on a two-day leave of absence as an involuntary patient of the Centre for Adult Psychiatry in Brandon at the time of his death. Date of inquest report -- April 7, 2016; Status of review -- completed August 31, 2017.
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336.02 KB
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Brian McPherson – 2016-02-09
Link to inquest report
Brian McPherson died on August 27, 2011 as a result of heart failure while in custody at the Garden Hill First Nation holding cells. Date of inquest report -- February 9, 2016; Status of review -- completed September 6, 2017.
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363.50 KB
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Heather Brenan – 2015-12-29
Link to inquest report
Heather Brenan remained in Seven Oaks General Hospital (SOGH) from January 24, 2012 to January 27, 2012 but was never admitted to a ward. She was discharged on January 27, 2012 at 10:35 p.m., arrived home in a taxi and dropped off in her back lane. She collapsed at her home and was returned to the emergency department of SOGH on January 28, 2012 where she died. Date of inquest report – December 29, 2015; Status of review – completed February 7, 2020.
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1.81 MB
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MA – 2015-12-23
Link to inquest report
MA, a youth serving a sentence in the community, died on August 30, 2010 in Winnipeg as a result of suicide by hanging. Date of inquest report -- December 23, 2015; Status of review -- As there were no recommendations for the ombudsman to monitor, there is no final report to the provincial chief judge.
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Drianna Ross – 2015-12-17
Link to inquest report
Drianna Ross died on November 26, 2011 of a methicillin-resistant staphylococcus aureus infection at the Thompson General Hospital. Date of inquest report -- December 17 2015; Status of review -- pending.
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Demus James, Throne Kirkness and Kayleigh Okemow – 2015-10-30
Link to inquest report
Demus James, Throne Kirkness and Kayleigh Okemow died on March 14, 2011 as a result of a house fire at God's Lake, Manitoba. Date of inquest report: October 30, 2015; Status of review: completed September 23, 2016.
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323.93 KB
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Errabella Angel Harper – 2015-10-30
Link to inquest report
Errabella Harper died in a house fire on January 16, 2011 in the community of St. Theresa Point. Date of inquest report – October 30, 2015; Status of review – completed September 23, 2016.
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323.93 KB
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Calvin Waylon McDougall – 2015-07-20
Link to inquest report
Calvin McDougall died on May 7, 2009 as a result of hanging while in a holding cell on Garden Hill First Nation. Date of inquest report -- July 20, 2015; Status of review -- completed August 31, 2017.
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411.10 KB
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James Livingston – 2015-06-23
Link to inquest report
James Livingston died by suicide on April 19, 2012 at the Health Sciences Centre in Winnipeg where he was being held under the Mental Health Act. Date of inquest report -- June 23, 2015; Status of review -- completed June 25, 2018.
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338.55 KB
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Frank Alexander – 2015-05-29
Link to inquest report
Frank Alexander, a resident of Parkview Place Personal Care Home in Winnipeg, died on March 28, 2011 after being assaulted by another resident on March 24, 2011. Both residents had a history of Alzheimer's disease. An autopsy concluded the death was a result of blunt head trauma; Date of inquest report – May 29, 2015; Status of review – completed March 20, 2019.
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2.08 MB
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Brian Lloyd Sinclair – 2014-12-12
Link to inquest report
Brian Sinclair died on September 21, 2008 while waiting for an extended period of time in the emergency department at the Health Sciences Centre in Winnipeg. Date of inquest report -- December 12, 2014; Status of review -- completed March 11, 2019.
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3.66 MB
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Jeffrey Ray Mallett – 2014-12-05
Link to inquest report
Jeffrey Mallett died of pneumonia on July 19, 2008 while in custody at the RCMP holding cells in Thompson, Manitoba. Date of inquest report -- December 5, 2014; Status of review -- completed May 9, 2018.
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364.18 KB
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Douglas Leon Sanderson – 2014-06-02
Link to inquest report
Douglas Sanderson died on November 30, 2009 at the Health Sciences Centre in Winnipeg after suffering head injuries as a result of a fall at the Main Street Project. Date of inquest report -- June 2, 2014; Status of review -- completed November 5, 2018.
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1.92 MB
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Robert Wood – 2014-05-29
Link to inquest report
Robert Wood died on January 3, 2010 as a result of head trauma due to falls while in custody of the RCMP in Nelson House, Manitoba. Date of inquest report -- May 29, 2014; Status of review -- completed November 25, 2016.
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227.38 KB
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Donald Ray Moose – 2014-05-15
Link to inquest report
Donald Moose died on October 2, 2009 of heart disease at the Grace General Hospital in Winnipeg. He was a resident of Headingley Correctional Centre. Date of inquest report -- May 15, 2014; Status of review -- completed September 21, 2017.
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2.72 MB
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Ann Hickey – 2014-02-14
Link to inquest report
Ann Hickey died on March 29, 2011 at Portage District General Hospital in Portage la Prairie, Manitoba as a result of strangulation from the pressure of a wheelchair seatbelt on her neck in a common room at the Manitoba Developmental Centre in Portage la Prairie on March 25, 2011. Date of inquest report – February 14, 2014; Status of review – completed November 21, 2016.
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457.04 KB
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Rudolph James Starr – 2013-11-27
Link to inquest report
Rudolf Starr died on June 22, 2009 in Selkirk, Manitoba after RCMP officers attempted to calm his erratic behaviour due to a drug overdose. Date of inquest report -- November 27, 2013. Status of review -- completed September 21, 2017.
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1.14 MB
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Wilfred Lesley Asham – 2012-10-12
Link to inquest report
On September 2, 2007 Wilfred Asham and another male were apprehended by members of the Winnipeg Police Service as they attempted to flee from a stolen vehicle. While in custody at the Public Safety Building, Mr. Asham collapsed. Despite resuscitation attempts by the Winnipeg Fire Paramedic Service and emergency staff at the Health Sciences Centre, Mr. Asham was pronounced dead. An autopsy report concluded that the immediate cause of death was "probable cardiac arrhythmia." Date of inquest report – October 12, 2012; Status of review – completed February 14, 2019.
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1.83 MB
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Nathan Michael Boryskavich – 2012-08-17
Link to inquest report
Nathan Boryskavich died on November 29, 2008 in The Pas Hospital as a result of acute hemorrhage due to traumatic disruption of his right vertebral artery. He had been taken to the hospital by the RCMP. Date of inquest report – August 17, 2012; Status of review: completed September 6, 2012. No final report.
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CJ and CB – 2012-07-06
Link to inquest report
CJ died July 30, 2010 and CB died December 11, 2010. Both deaths occurred at the Manitoba Youth Centre; Date of inquest report – July 6, 2012; Status of review – completed 2018.
2024-03-25_MO-00333_Inquest monitoring report_.pdfDownload
282 KB
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Ahmad Saleh-Azad – 2011-09-30
Link to inquest report
Ahmad Saleh-Azad died on March 27, 2007 as the result of a gunshot wound sustained during confrontation with the Winnipeg Police Service at Madison Memorial Lodge in Winnipeg, where Mr. Saleh-Azad was a resident. Date of inquest report -- September 30, 2011; Status of review -- completed November 19, 2014.
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743.62 KB
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Maurice Paul Thomas – 2011-07-20
Link to inquest report
Maurice Thomas died on May 7, 2008 as a result of a brain injury after being placed in the Main Street Project in Winnipeg. Date of inquest report -- July 20, 2011; Status of review -- completed October 24, 2016.
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354.58 KB
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Cheryl Lynn Tom – 2011-07-07
Link to inquest report
Cheryl Tom died of a drug overdose on March 26, 2007 while at the Main Street Project in Winnipeg after being detained by police under the Intoxicated Persons Detention Act. Date of inquest report -- July 7, 2011; Status of review -- completed October 24, 2016.
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331.19 KB
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Andrew Szabo – 2011-06-17
Link to inquest report
Andrew Szabo died on August 5, 2006 after falling from the stands at Canad Inns Stadium while attending a football game. Date of inquest report -- June 17, 2011; Status of review -- completed May 7, 2012.
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75.45 KB
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Shawn Jones, Raynold Gerling and Brian Palmquist – 2010-11-05
Link to inquest report
Shawn Jones died on May 12, 2006, Raynold Gerling died on December 11, 2006 and Brian Palmquist died on November 18, 2007. All three men died of drug overdoses while at the Stony Mountain Institution. Date of inquest report -- November 5, 2010. Status of review -- completed on June 6, 2011.
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26.66 KB
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Russell Cook – 2009-11-26
Link to inquest report
Russell Cook died on October 26, 2006 in Winnipeg following an incident where he was forcibly restrained by bystanders and staff at a private business. Date of inquest report – November 26, 2009; Status of review – completed April 5, 2011.
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31.23 KB
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Darlene Rose Owens – 2009-05-06
Link to inquest report
Darlene Owens died on October 19, 2005 as a result of suicide by hanging while detained in RCMP holding cells in Pauingassi First Nation. Date of inquest report -- May 6, 2009; Status of review -- completed February 22, 2010.
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49.98 KB
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Alan Earle Rupert – 2009-04-22
Link to inquest report
Alan Rupert died on February 13, 2005 at the Health Sciences Centre in Winnipeg as a result of aspiration pneumonia after a spine fracture sustained during a fall while in the custody of the Winnipeg Police Service. Date of inquest report -- April 22, 2009; Status of review -- completed January 28, 2011.
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48.18 KB
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Matthew Adam Joseph Dumas – 2008-12-04
Link to inquest report
Matthew Dumas died on January 31, 2005 in Winnipeg after being shot by a member of the Winnipeg Police Service. Date of inquest report – December 4, 2008; Status of review – completed May 28, 2009.
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115.97 KB
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Stephen Ewing – 2008-11-04
Link to inquest report
Steven Ewing died on August 16, 2000 at the Health Sciences Centre in Winnipeg as a result of injuries from an explosion (or series of explosions) that occurred while working for a mining company in Flin Flon, Manitoba. Date of inquest report – November 4, 2008; Status of review – completed February 7, 2013.
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33.39 KB
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Tracia Owen – 2008-01-16
Link to inquest report
Tracia Owen died on August 24, 2005 as a result of suicide by hanging while in the care of a child and family services agency. Date of inquest report -- January 16, 2008. Status of review -- completed May 17, 2019.
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2.55 MB
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Mitchell Adam Audy – 2007-10-09
Link to inquest report
Mitchell Audy died in Swan River, Manitoba on November 22, 2003 as a result of blunt trauma to the chest. This death occurred following initial treatment at the Swan River Valley Hospital and subsequent detention at the Swan River RCMP detachment under the Intoxicated Persons Detention Act; Date of inquest report – October 9, 2007; Status of review – completed January 20, 2009.
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80.14 KB
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Sherrill Wilfred Forbister – 2007-08-21
Link to inquest report
Sherrill Forbister died while in RCMP custody in Norway House, Manitoba on October 16, 2003 as a result of an alcohol and drug overdose. Date of inquest report – August 21, 2007; Status of review – completed May 23, 2008.
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34.06 KB
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Paul Laurent Joubert – 2007-08-03
Link to inquest report
Paul Joubert died at the Health Sciences Centre's PsycHealth Centre in Winnipeg on January 31, 2005 as a result of hanging. He had been transferred to the PsycHealth Centre from the Brandon Correctional Centre. Date of inquest report -- August 3, 2007; Status of review -- completed January 22, 2009.
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33.05 KB
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Rachel Lori Wood – 2007-05-29
Link to inquest report
Rachel Wood died on October 5, 2003 as a result of hanging while in police custody at Nisichawayasihk Cree Nation (Nelson House). Date of inquest report -- May 29, 2007; Status of review -- completed July 10, 2008.
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36.88 KB
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Christopher John Holoka – 2007-05-11
Link to inquest report
Chistopher Holoka died in Winnipeg on April 15, 2005 as result of methadone poisoning at the Winnipeg Remand Centre. Date of inquest report – May 11, 2007; Status of review – completed March 5, 2010.
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54.60 KB
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Dennis Robinson – 2007-03-26
Link to inquest report
Dennis Robinson died on February 28, 2004 as a result of an epileptic seizure at the Manitoba Developmental Centre in Portage la Prairie, Manitoba. Date of inquest report -- March 26, 2007. Status of review -- completed January 6, 2009.
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135.63 KB
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Peter Stevenson – 2006-10-25
Link to inquest report
Peter Stevenson died of cardiac arrest on September 2, 2004 at The Pas Health Complex. Date of inquest report -- October 25, 2006. Status of review -- completed December 24, 2010.
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347.69 KB
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Keyanna Marie Snowdon – 2006-08-01
Link to inquest report
Keyanna Snowdon died on May 12, 2004 by drowning at her foster home in Winnipeg. Date of inquest report -- August 1, 2006; Status of review -- completed January 4, 2012.
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222.46 KB
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Dennis Junior St. Paul – 2006-07-14
Link to inquest report
Dennis St. Paul died on January 3, 2005 in Norway House, Manitoba as a result of a gunshot wound sustained while being apprehended by the RCMP. Date of inquest report -- July 14, 2006; Status of review -- completed June 10, 2008.
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21.79 KB
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Sharon Joyce Horn – 2006-06-08
Link to inquest report
Sharon Horn was discovered frozen on January 3, 2004 in Brandon, Manitoba. Date of inquest report --- June 8, 2006; Status of review – completed July 14, 2010.
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80.34 KB
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Eric Clipping – 2006-04-20
Inquest report is available only in print from the Office of the Chief Medical Examiner
Eric Clipping was treated on June 23, 1995 at the Health Sciences Centre (HSC) in Winnipeg after being found injured. He was then taken to the Main Street Project but transported back to the HSC where he underwent emergency surgery. He was later transferred to a nursing facility in Churchill, Manitoba, where he remained until his death on April 28, 1996. Date of inquest report – April 20, 2006; Status of review – completed October 21, 2008.
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19.22 KB
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Anna Maciocha – 2006-03-06
Link to inquest report
Anna Maciocha died on April 5, 2004 as a result of suicide while an involuntary patient at the PsycHealth Unit at the Health Sciences Centre in Winnipeg. Date of inquest report -- March 6, 2006; Status of review -- completed December 19, 2011.
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72.76 KB
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Calvin Sean Wood – 2005-11-28
Link to inquest report
Calvin Wood died on January 23, 2002 when his truck went through the ice on an ice road between Wasagamack and St. Theresa's Point. Date of inquest report -- November 28, 2005; Status of review -- completed on February 21, 2008.
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36.21 KB
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Ettie June Morris – 2005-09-07
Link to inquest report
Ettie Morris died of cardiac arrest on January 4, 2002 after receiving an excessive dose of potassium while awaiting hip surgery at St. Boniface General Hospital in Winnipeg. Date of inquest report -- September 7, 2005; Status of review -- completed on November 25, 2011.
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122.13 KB
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Leon Herman Bighetty – 2005-08-02
Link to inquest report
Herman Bighetty died at the Health Sciences Centre in Winnipeg on November 27, 2002 from subdural hematomas, six days after being found unresponsive in his cell at the Main Street Project, where he was detained after being apprehended by the Winnipeg Police Service under the Intoxicated Persons Detention Act; Date of inquest report – August 2, 2005; Status of review – completed June 30, 2008.
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42.13 KB
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John Erik Demery – 2003-12-22
Link to inquest report
John Demery died in Winnipeg at his residence on August 15, 2003 as a result of bronchopneumonia. He had been either a ward of Winnipeg Child and Family Services, or had been under voluntary placement, from birth until May 2003. Date of inquest report – December 22, 2003; Status of review – completed December 9, 2010.
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27.41 KB
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