The Minister of Justice may order that a Provincial Court judge conduct a public fatality inquiry. The inquiry will determine the identity of the deceased; the date, time and place of death; and the circumstances of death. Once the inquiry is complete the judge provides a written report.
The judge may make recommendations for the prevention of similar incidents, but can't make any findings of legal responsibility.
Public fatality inquiry reports are organized by year of issue, with the most current decisions listed first. The search page may be used to find decisions using specific keywords.
Report to the Attorney General : Public Inquiry into the death of Kevin Goodhope 
November 19, 2009
On January 20, 2008, Kevin Goodhope was found suspended by his neck in his room at Alberta Hospital, Edmonton. He was resuscitated and transferred to hospital. His condition continued to deteriorate and he died on January 21, 2008.
Report to the Attorney General: Public Inquiry into the death of Colleen Akazay
October 30, 2009
On February 18, 2006, Colleen Akazay was found unresponsive in her cell at the Grande Prairie RCMP Detachment. She died from an overdose of prescription drugs and alcohol.
Report to the Attorney General: Public Inquiry into the death of Todd Stevenson
September 24, 2009
On September 10, 2005, Todd Stevenson was a victim of a physical attack at the Edmonton Remand Centre. Emergency Medical Services arrived shortly after and determined he was unresponsive.
Report to the Attorney General: Public Inquiry into the death of Darren Cardinal
September 21, 2009
On June 30, 2006, in the basement of a duplex unit in Edmonton, Darren Cardinal was shot during an exchange of handgun fire with police officers.
Report to the Attorney General: Public Inquiry into the death of Carrie Rivait
September 10, 2009
On November 11, 2004, Carrie Rivait was found unresponsive at a private residence in Calgary while on statutory release. She died as a result of a drug overdose.
Report to the Attorney General: Public Inquiry into the death of Sydney Salter
September 01, 2009
On December 31, 2007, Sydney Salter was found in sub-zero temperatures lying on a sidewalk outside a retirement home where he lived in Lethbridge. The cause of death was determined to be hypothermia due to cold exposure.
Report to the Attorney General: Public Inquiry into the death of Jarrett Jabs
Report to the Attorney General: Public Inquiry into the death of Jarrett Jabs
See related - Appendix A: CSC's Internal Investigation Process
See related - Appendix B: Sample of media coverage related to incidents in federal correctional facilities
See related - Appendix C: Federal Prison Ombudsman Releases Study on Deaths in Custody: Report Finds Some Fatalities Could Have Been Averted
See related - Appendix D: Deaths in Custody Final Report
See related - Appendix E: Annual Report of the Office of the Correctional Investigator 2006-2007
July 17, 2009
On November 13, 2001, in Drumheller Institution, inmate Jarrett Jabs was the victim of blunt cranial trauma and a stab wound to the neck by other inmates.
Report to the Attorney General: Public Inquiry into the death of Boris Marianych
July 16, 2009
On February 20, 2007, Boris Marianych was found unresponsive in his cell at the Red Deer Remand Centre.
Report to the Attorney General: Public Inquiry into the death of Eric Encontre
June 29, 2009
On October 3, 2006, Eric Encontre was found unresponsive in his cell at the Calgary Correctional Centre.
Report to the Attorney General: Public Inquiry into the death of D.B.
June 11, 2009
On January 2, 2006 on Siksika Nation, D. B.** was found suspended by her neck in the basement of her home.
** The Child, Youth and Family Enhancement Act prohibits publishing the name of the child.
Report to the Attorney General: Public Inquiry into the death of Jonathan Martin
June 01, 2009
On August 5, 2006, Jonathan Martin was observed sitting hunched over the north rail track in Edson, Alberta. He made no attempt to avoid being hit by the train.
Report to the Attorney General: Public Inquiry into the death of Stephanie Titus
May 19, 2009
On December 7, 2006, while travelling on Highway 13 near Killam, Stephanie Titus died after her vehicle was stuck by pipe falling off the deck of an oncoming semi-trailer.
Report to the Attorney General - Public Inquiry into the death of Jason Doan
May 13, 2009
On August 10, 2006, in Red Deer, Jason Doan was witnessed exhibiting strange and violent behaviour. After being electronically stunned by police he became unresponsive and suffered cardiac arrest. He was transported to hospital and died on August 30, 2006.
Report to the Attorney General - Public Inquiry into the death of Jordon Neave
May 07, 2009
On May 20, 2006, Jordan Neave was found unresponsive in the Olds Aquatic Centre public swimming pool.
Report to the Attorney General - Public Inquiry into the death of Diana Yano
April 27, 2009
In Calgary on August 18, 2006, Diana Yano jumped from the third floor of a hospital parking structure.
Report to the Attorney General - Public inquiry into the death of Shannon Red Crow
April 24, 2009
On September 14, 2006, in Glenwood, Shannon Red Crow was a rear-seat passenger in a vehicle being pursued by the Blood Tribe Police when the vehicle veered off the roadway and hit a dry river embankment.
Report to the Attorney General - Public inquiry into the death of James Rolheiser
April 15, 2009
On August 28, 2006, the skeletal remains of James Rolheiser were found on the banks of the
North Saskatchewan River. He attended at hospital with suicidal ideation on May 16, 2006, and was discharged.
Report to the Attorney General - Public inquiry into the death of Wayne Roland Tuccaro
April 06, 2009
On June 23, 2006, Wayne Tuccaro died of a self-inflicted gunshot wound to his chest after a police chase in Edmonton.
Report to the Attorney General - Public inquiry into the death of Sheldon Houston
February 18, 2009
Sheldon Houston was the sole passenger in a single-vehicle crash on the Deerfoot Trail in Calgary on November 7, 2006.
Report to the Attorney General - Public inquiry into the death of Michael Berggren
February 04, 2009
On December 26, 2006, near Hines Creek, Michael Berggren was involved in a single vehicle rollover. A toxicology screen showed he had Estazolam, a tranquilizer, in his system. Further screening of a herbal supplement he had been known to take was positive for the same drug, although it was not a declared ingredient. Estazolam is a controlled substance in Canada.
Report to the Attorney General - Public inquiry into the death of Kevan John Chandler
January 27, 2009
On June 18, 2006, near High River, Kevan John Chandler was found unresponsive in a grain silo beneath a large amount of grain.
Report to the Attorney General - Public inquiry into the death of Leland Auger
January 23, 2009
On May 28, 2006, in Desmarais, Leland Auger was ejected from a vehicle during a high speed police chase and died instantly.
Report to the Attorney General - Public inquiry into the death of Dennis Karey
January 22, 2009
On April 30, 2005, Dennis Karey was found unresponsive in his cell at the Lethbridge Correctional Centre. The cause of death was methadone overdose.
Report to the Attorney General - Public inquiry into the death of Sharla Marie Collier
January 19, 2009
On November 16, 2002, Collier was found in a wooded area a short distance from the group home at which she worked near the University of Lethbridge. She died from head injuries sustained from blunt force impacts to the left side of her head.
Report to the Attorney General - Public inquiry into the death of Mary Marguerite Leet
January 13, 2009
On May 12, 2006, Mary Marguerite Leet broke the window of her 6th floor hospital room at the
Foothills Medical Centre in Calgary and fell to her death.