MONTREAL - A Montreal-area Inuit health centre should review its security measures in light of the deaths of two patients who were struck and killed on highways within a 24-hour span in 2022, a Quebec coroner's report says.
Coroner Éric Lépine examined the death of one of the two women — Mary-Jane Tulugak, 22 — and issued a series of recommendations in his report released Thursday.
Tulugak and Nellie Niviaxie, 26, had both travelled to Montreal for medical treatment and had been staying at the Ullivik health centre, in Dorval, Que., which is overseen by the health board in Nunavik, the northern Quebec territory where the two women lived.
Opened in 2016, the centre is a place to stay for Inuit from remote northern communities who need special care or who are accompanying someone receiving medical treatment.
On Aug. 19, 2022, Tulugak, who was using a wheelchair after ankle surgery, was barred entry to Ullivik's living quarters by security because she arrived after 3 a.m., following a night of drinking. She was brought to Ullivik by Montreal police, who had found her intoxicated.
The coroner's report said Tulugak, a mother of three from Puvirnituq, Nunavik, roamed the ground floor of the centre for about 30 minutes but then left and was fatally struck about 380 metres away on Highway 520 about 4:15 a.m., with her death confirmed at a nearby hospital. She had been in Montreal since late July awaiting surgery.
Lépine says the health centre's protocols stated that a supervisor should have been informed about Tulugak's attempted entry to the centre's living quarters, but the coroner says that person was on a break and wasn't informed until after the patient had left. Ullivik had a policy of preventing potentially intoxicated people from accessing certain parts of the lodge.
Niviaxie, of Umiujaq, Nunavik, died less than 24 hours later after she was hit multiple times on Highway 20, not far from where Tulugak died.
Lépine ruled Tulugak's death accidental. Among his dozen recommendations is that Ullivik security personnel be given specific instructions to ensure a manager is present at all times. The coroner also recommended the centre rehire a social worker — a post that had been eliminated during budget cuts — as well as a spiritual guide.
As well, Lépine said the Nunavik health board should brief patients on security matters before they travel south.
"It would be useful for those who are on their first stay to receive before their departure a minimum amount of information on questions surrounding security during their stay in the city," the coroner wrote. "This information should be transmitted in their mother tongue so as to ensure it has been properly understood."
The local bar, Café-Bar Dorval, should train staff on preventing overconsumption of alcohol, and its management should meet with Ullivik officials to better understand the realities of the health centre's patients, Lépine's report said.
McGill University Health Centre, the primary care facility for northern patients, should consider prioritizing procedures for northerners so that they avoid a lengthy stay in Montreal, he recommended.
Lépine says many of his recommendations have already been implemented and that the municipality installed trilingual pedestrian crossings in English, French and Inuktitut last year.
Rita Novalinga, executive director of Ullivik, said in an email that the centre has taken a "proactive approach … to prevent similar tragedies and ensure that the centre continues to be a safe and caring place for those in need, whether through our internal services, or by assisting in supervising residents outside the facility."
This report by ºÚÁϳԹÏÍø was first published July 4, 2024.
