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 circumstances similar to those that resulted in the death that is the subject of the inquest.

Many of the deaths into which inquests are held occur in circumstances that could also be the subject of investigations by the Ombudsman. 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.

In recent years, the majority of the inquests have been mandatory under subsection 19(3) of The Fatality Inquiries Act, which requires that an inquest be held where there are reasonable grounds to believe:

...that a person while a resident in a correctional institution, jail or prison or while an involuntary resident in a psychiatric facility defined in The Mental Health Act, or while a resident in a developmental centre as defined in The Vulnerable Persons Living with a Mental Disability Act died as a result of a violent act, undue means or negligence or in an unexpected or unexplained manner or suddenly of unknown cause; or that the person died as a result of an act or omission of a peace officer in the course of duty.

 

Inquest reports are published on the Manitoba Courts web site. To date, follow-up reports by the Ombudsman to the Chief Judge have not been published and the public has not been informed of the provincial and municipal governments' responses to the recommendations.

In order to provide greater transparency to this process, the Chief Judge has agreed that the Ombudsman may publish the letters that are written to the Chief Judge advising of the responses to the inquest report recommendations within the jurisdiction of the Ombudsman.

In order to provide context for the public, an Inquest Reporting Table has been developed for the Ombudsman web site to provide information about the deceased (name, date, place and cause of death), date of the inquest report, whether the deceased was an adult or a child, a list of the inquest recommendations and the provincial or municipal department/agency to which they are directed, and the status of the response to the recommendations. The table has links to the full text of the Inquest Report and the Ombudsman's closing letter to the Chief Judge, detailing the response to each of the recommendations.

This system of reporting commenced as of January 2008, and the web site includes all inquests where the response from the Ombudsman to the Chief Judge was pending. It does not include inquests where the Ombudsman file was already concluded. As new inquest reports and closing reports become available they will be added to the web site.