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Changing how funding decisions are made for families’ lawyers during inquests and creating a task force to address the “devastating impact” of addictions are among the recommendations in a report on a man swallowing a lethal amount of drugs.
Provincial court Judge Robin Finlayson’s final report into the November 2020 death of James Stewart was released Tuesday, after an inquest held over several days from May to October 2025. Stewart was from St. Laurent, Man., a 2023 news release said.
The report said it appeared Stewart, described as a long-time drug user and addict who was 40 years old, had just gotten a large quantity of drugs and was packaging it for resale when he encountered Winnipeg police the day he died.
The two officers who arrested Stewart told the inquest they came across a truck parked in a back lane and decided to do a “routine check” of the vehicle. Stewart drove away in the truck before eventually being arrested, the report said.
Finlayson wrote that Stewart, afraid of being detained in police custody, “panicked as one might expect” and swallowed foil-wrapped drugs.
“The amount of drugs that he consumed during this time was a lethal quantity. When the foil that the drugs were wrapped in started to come apart some time later. the overdose of illegal drugs caused the almost immediate death of Mr. Stewart,” the report said.
Stewart’s sister told the inquest she and her siblings were adopted early in their childhoods and ended up being “abused in many respects” by that family, something she said was “particularly difficult” for him. He started using cocaine at around age 15 and began “hanging with the wrong people” in the years that followed, she said.
By the time he was 21, he was using the drug regularly and sometimes going on long binges, part of the evidence Finlayson said made it clear Stewart was “a hard-core addict” by age 21 and that there was no evidence he tried to get counselling or help with his addiction.
Seizure in cell
Stewart told police he’d swallowed three to five rocks of crack cocaine, and later told a paramedic he’d consumed three to four rocks of cocaine and four points — or about four-tenths of a gram — of methamphetamine. The inquest report said his death was caused by “a self-administered quantity of illegal drugs commonly known as methamphetamine.”
Stewart was handcuffed and put in the back of the officers’ vehicle and charged with drug and driving offences. Police had found crack cocaine and drug paraphernalia in the truck and cash in Stewart’s jacket pocket, and learned his licence had been suspended.
Stewart declined medical attention on the way to the police central processing unit, and at one point became erratic and started banging his head inside the vehicle, the inquest report said.
Once at central processing, Stewart was taken to see the paramedic, who treated a cut to his forehead and said she would check on him. That paramedic told the inquest Stewart’s vital signs were mostly within normal limits. He was a bit sweaty, but she attributed that to his becoming agitated and hitting his head in the police vehicle.
Stewart was detained in a cell, where the paramedic said she planned to check on him in 30 minutes. Within 15 minutes, she was advised he was having a seizure and found him only slightly responsive.
She then called an ambulance, the inquest report said. When she found Stewart had no pulse, CPR was started and continued until the ambulance got there about 10 to 15 minutes later. Stewart was pronounced dead in hospital.
Addictions problem ‘continues to get worse’
Finlayson’s recommendations included one related to compensation for families’ lawyers during inquests, after the lawyer who represented Stewart’s family was denied government funding.
Finlayson said he wasn’t recommending all families get government-compensated inquest counsel but did suggest “some greater latitude be exercised by government and its officials as to whether an inquest judge could be better served by having counsel appointed and properly funded to represent families left behind by such tragedies as the death of Mr. Stewart.”
The province can provide funding for legal expenses related to inquests but says on its website it will only consider such requests “in extraordinary cases.”
Finlayson also recommended a “multi-level empowered task force” to address the ongoing issue of addiction, a step he described as “not only ideal” but necessary.
“Every day, the criminal dockets are jammed with those suffering from severe addiction. The problem continues to get worse. Government cannot allow these drugs to run our communities,” he wrote.
“Strategies need to be developed by our best experts in all fields working together at the highest level and supported completely by government to deal with the ongoing problems caused by this epidemic.”
A third recommendation, which was implemented shortly after Stewart died, requires a person in police custody be taken to hospital for medical clearance in a number of circumstances, including if they admit to having ingested drugs to hide them.
An emailed statement attributed to Bernadette Smith, Manitoba’s minister of housing, addictions and homelessness, said she has instructed her department “to look into ways to make the inquest process more accessible and less costly for families of the subjects of the inquiries.”
It also said the provincial government “agrees entirely” with Finlayson’s call for an addictions task force, which is why it launched the organized crime and drug trafficking task force earlier this year.
The statement said the task force “will provide Manitoba access to the best minds and practices in Canada for fighting back against the meth crisis and those who profit off of it.”