Recommendation Implementation Status Update – Inquest into the Death of Richard Kakish
inquest monitoring
health facility, body or trustee
Summary
Situation Leading to the Inquest:
Mr. Kakish was detained at the Winnipeg Remand Centre when he collapsed and was transported to Health Sciences Centre. It was determined that he had suffered internal injuries from a ruptured spleen that resulted in his death on August 13, 2017, two days after he collapsed. The inquest report examined the circumstances leading to his death and found that Mr. Kakish had contact with multiple police officers, health-care providers, and correctional staff over a short period following his arrest on August 9, 2017. Throughout these interactions, important information about the force used during his arrest, his reported injuries, and his ongoing medical condition was not consistently communicated. The inquest identified significant gaps in communication, information sharing, and continuity of care across the involved agencies. The inquest concluded that these failures contributed to missed opportunities to recognize and respond to Mr. Kakish’s deteriorating condition.
The Original Inquest Report Issued by The Provincial Court of Manitoba:
Link to inquest report
8 Recommendations
Judge Wanda Garreck issued an inquest report into the death of Richard Kakish on July 9, 2021. The report included eight recommendations to prevent a death in similar circumstances.
The public bodies involved or mentioned in the recommendations:
- Winnipeg Remand Centre (Department of Justice)
- Winnipeg Police Service (City of Winnipeg)
- Shared Health
- Winnipeg Regional Health Authority
Manitoba Ombudsman Recommendation Implementation Status Update Report
The recommendations made following the inquest into the death of Mr. Richard Kakish have resulted in Manitoba Justice and the Winnipeg Remand Centre, the Winnipeg Police, and health-care providers taking steps towards improving communication when responsible for individuals who are injured and in custody in the City of Winnipeg.
Of the eight recommendations:
- six have been implemented
- one has been partially implementing with ongoing progress
- one has been partially implemented
Details and the full report are available below.
MO-00309
MO-00309