The coroner who investigated the death of Joyce Echaquan concludes that “the racism and prejudices” which the Atikamekw woman faced at the Joliette hospital “were certainly contributory to her death”. At the top of its list of recommendations, it inscribes the need for the Government of Quebec to recognize “the existence of systemic racism within our institutions”.
In the report she filed Friday, Coroner Géhane Kamel insists on the disastrous impact of the prejudices of caregivers who have – wrongly – “labeled” Ms. Echaquan as being drug addicted. “Based on this prejudice, it follows that his appeals for help will unfortunately not be taken seriously,” she notes.
For that, she concludes that the death of Mrs. Echaquan was “accidental”: that it follows not only consequences of pulmonary edema, but also “potentially deleterious maneuvers” and “racism and [des préjugés » auxquels la patiente a fait face au Centre hospitalier de Lanaudière, couramment appelé hôpital de Joliette.
« Dans le cas de Mme Echaquan, si cela n’avait pas été de la captation vidéo, il y a fort à parier que cet évènement n’aurait jamais été porté à l’attention du public », écrit la coroner, qui a constaté plusieurs manquements dans le travail du personnel soignant. « Lorsque le système se replie défensivement sur lui-même, c’est la définition même du racisme systémique », ajoute-t-elle.
Dans un passage où elle rappelle que le débat sur le racisme systémique a fait son chemin jusqu’à l’Assemblée nationale, Me Kamel écrit qu’« il est désormais inacceptable que de larges pans de notre société nient une réalité aussi bien documentée ».
« Des efforts [vers la réconciliation] are all the more necessary since the conclusions of this investigation indicate that Ms. Echaquan was indeed ostracized, that her death is directly related to the care obtained during her hospitalization in September 2020 and that her death could have been avoided. The courage of words aimed at pacifying our relationships with others is crucial, ”insists the coroner.
To prevent a situation like that experienced by Ms. Echaquan from happening again, she recommends first “that the Quebec government recognize the existence of systemic racism within our institutions and undertake to contribute to its elimination.” “
Prejudices from start to finish
Me Kamel’s report also highlights the series of prejudices that guided the actions of caregivers who received Joyce Echaquan at the Joliette hospital. These prejudices followed the patient until her death.
Civilian witnesses said they heard healthcare workers express relief after his death. “The Indians, they like to complain about nothing, to be screwed and to have children. Worse, it is us who are paying for it. Finally, she is dead, ”heard these witnesses.
The day after Mrs. Echaquan’s admission to hospital, on September 27, a gastroenterologist spoke of “a possible withdrawal from narcotics and cannabis without real consumption preceding the episode being able to be demonstrated ”. This “drug addiction label” – also wrongly linked to other Aboriginals in the health network – guided “the actions of nursing staff until their death”.
“The medical staff even mentioned alcohol withdrawal, which is incorrect information,” said the coroner. “The evidence heard during the hearing also showed that Ms. Echaquan only consumes narcotics duly prescribed and the quantity of which is insufficient to create dependence,” she writes. Moreover, “no doctor or member of the staff of the integrated health and social services center of Lanaudière were able to tell us on what was based this diagnosis of drug addiction by Ms. Echaquan,” adds the coroner.
Again: The coroner notes that the Atikamekw patient appeared to be uncomfortable with being relieved with morphine. ” [Elle] reproached the workers in the health system for never resolving her pain and simply returning her home with painkillers, ”she wrote, recalling testimonies collected as part of an investigation by To have to.
In Joliette, Ms. Echaquan “received the label of difficult patient” and paid the price for “the lack of humanity of certain attendants and nurses”. According to a witness, caregivers launched: “she threw herself on the ground, you know well”, when the patient has had a fall.
A resident in gastroenterology also judged that Ms. Echaquan was not credible and “drug-dependent” according to her husband, “while she [avait] not spoken ”. This same resident noted that Ms. Echaquan was “calm” and “hardly awakening” while she was in “advanced coma”, a few minutes from death. She ignored the patient’s daughter’s requests for help, which she interpreted as “threats”.
Another doctor, responsible for hospitalizations, prescribed physical and chemical restraint (with an antipsychotic) to her Atikamekw patient, saying she wanted to “calm her down as necessary”, according to a witness. The doctor has “ratified[é] the judgment made by his colleagues and surety[é] a diagnosis of withdrawal which is however not supported by any evidence ”, laments the coroner. Worse: Ms. Echaquan found herself “nailed to her stretcher without the possibility of standing up, a natural gesture when there is an accumulation of water on the lungs”, reads the report.
In the light of the testimonies, Me Kamel recommends that the College of Physicians “review the quality of the medical acts” of this resident and this physician.
An intern with 4 months of experience
On the morning of her death, Joyce Echaquan was under the responsibility of a candidate for the practice of the nursing profession (CEPI), a trainee with “a little less than four months of experience”.
In the minutes preceding the death of Ms. Echaquan, she was “left on her own,” notes the coroner. She qualifies as “simply not credible” the version of the facts of the doctor who says to have come to the first call to help the trainee, since “several witnesses heard the repeated calls of the CEPI to the microphone for medical assistance “.
It is also to the CEPI and to the attendants, too busy, that were entrusted the task of carrying out a close supervision of Mrs. Echaquan when she was under restraints.
“At no time were alternative measures offered to alleviate Ms. Echaquan’s fears. […] This idea of cultural support has never crossed the mind of any member of the hospital’s healthcare community, this despite the availability and presence in due form of an Aboriginal liaison officer », note Me Kamel.
The choice of restraint “was certainly not an optimal solution in the circumstances”, judges the coroner. Regarding the Native Liaison Officer, she adds: “We have to admit that this position gave the CISSS a clear conscience, but was definitely not exploited to its full potential. In fact, the liaison officer is at most a trinket placed on a shelf to look pretty ”.
Me Kamel also notes that the use of CEPI – “this solution [créée] to cope with the staff shortage – created “significant risks for patients staying in the emergency room” of the Joliette hospital. “This situation was in itself herald of slippages. “To do this, she recommends that the Order of Nurses review” the practices for integrating CEPIs at the college level into hospital emergencies across the province “.
The coroner also suggests that the CISSS de Lanaudière and the Ministry of Higher Education take various actions to include Indigenous realities in training and care.
She also recalls that the nurse and the beneficiary attendant who uttered insults against Ms. Echaquan never admitted having “a racist bias”. “The mere fact of not admitting to having a bias is even more heartbreaking, because it illustrates this lack of compassion towards a human being,” she writes.
Géhane Kamel heard from 44 witnesses during the public hearings which led to the tabling of this report.