The deceased came to his death on the 28th day of March 2011 at the City of WINNIPEG, in the Province of Manitoba. [...] Page: 2 I. THE CALLING OF THIS INQUEST [1] The Chief Medical Examiner for the Province of Manitoba, Doctor A. Thambirajah Balachandra, sent a letter bearing date October 16, 2012 to the Chief Judge of the Provincial Court directing that, in accordance with The Fatality Inquiries Act (the “Act”), an inquest be held into the death of Frank Alexander for the following reasons: 1. to determine the cir [...] The primary role of the judge at an inquest is to determine the identity of the deceased, when, where, and by what means, the deceased person died, the cause of death, the material circumstances under which the death occurred and whether the death could have been prevented. [...] Further, a judge may recommend changes in the programs, policies or practices of the government and relevant public agencies or institutions or in the laws of the province, where the judge is of the opinion that such changes would serve to reduce the likelihood of deaths in similar Inquest: Frank Alexander. [...] Section 33(2) of the Act prohibits a judge from expressing any opinion on or making a determination with respect to culpability in respect of the death that is the subject of the inquest.