Recommendation Monitoring of the Inquest into the Death of Bradley Errol Greene

2026-05-27

Summary

Situation Leading to the Inquest:

The circumstances surrounding Mr. Greene’s death began on April 30, 2016, when Mr. Greene was admitted to the Winnipeg Remand Centre. He advised staff 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 and died later that evening. He received no seizure medication while being held at the Winnipeg Remand Centre.

The Original Inquest Report Issued by The Provincial Court of Manitoba:

Link to inquest report

11 Recommendations

The Honourable Judge Heather Pullan issued an inquest report into the death of Bradley Errol Greene on June 11, 2019. Her report included eleven recommendations to prevent a death in similar circumstances.

The public bodies involved or mentioned in the recommendations:

Winnipeg Remand Centre (Department of Justice)
Community Safety Division (Department of Justice)
Manitoba Health

Manitoba Ombudsman Recommendation Implementation Status Update Report

The recommendations made following the inquest into the death of Mr. Bradley Errol Greene marked a turning point for change in how medical services are delivered in correctional centres. However, the resulting changes have been slow.

Of the eleven recommendations:

one has been declined by the department as not feasible
five are implemented
two not implemented
three are partially implemented with ongoing progress

It is noted that recommendations specifying the implementation of accreditation and a comprehensive review of the Winnipeg Remand Center medical unit, as well as the transition of health services from Manitoba Justice to Manitoba Health, have not yet materialized. We will continue to monitor the plan for transitioning inmate medical services to Shared Health and may issue a further public statement on this work.