Coroner calls for review of security measures at Inuit centre following deaths of 2 women

A Quebec coroner is calling for a review of security intervention measures at the Ullivik lodging centre in Dorval after two Inuit women staying there were struck and killed by vehicles on nearby highways, less than 24 hours apart, in August 2022.

Ullivik, located near Montreal's Trudeau Airport, opened in 2016 as a place where Inuit patients could stay when they flew south for medical care.

Coroner Éric Lépine made 12 recommendations in his report published Thursday, writing he hopes they will ensure better protection of human life in the area.

On Aug. 19, 22-year-old Mary-Jane Tulugak from Puvirnituq, had been heading down Highway 520 in a wheelchair near the lodging centre before she was hit by a vehicle around 4 a.m. She died in hospital soon after.

Less than 24 hours later, 26-year-old Nellie Niviaxie from Umiujaq died after being struck multiple times on Highway 20 around 1:20 a.m.

According to the coroner's report into Tulugak's death, the mother of three had flown to Montreal to undergo ankle surgery following a fracture. She was housed at the Ullivik centre awaiting her surgery, which finally took place after three weeks.

On the evening following her surgery, Tulugak left the lodging centre in a cast and wheelchair and headed to Café-Bar Dorval, a nearby bar, where she stayed until closing.

Officers with the Service de police de la ville de Montréal (SPVM) reportedly found the woman travelling near a roundabout around 3:20 a.m. They said she was heavily intoxicated and brought her back to the centre.

Security guards at Ullivik tried to deny her entry into her room because of her level of intoxication. Eventually, Tulugak made it upstairs to her room but returned to the ground floor shortly after.

After about 30 minutes, Tulugak called a taxi before leaving the scene in a wheelchair. She died soon after.

No intervention from security guards

In his report, Lépine said Tulugak's behaviour upon arriving back to the centre — including agitation and a tendency to walk on her partially undone cast instead of using the wheelchair next to her — were all indicators of an abnormal condition.

According to protocol, Tulugak should have been referred to the person in charge of the living unit, who could have offered her assistance. But that person was on break when Tulugak returned and was not alerted about her behaviour until she'd already left.

"For almost 30 minutes, she moved around the common areas without any particular intervention from the security guards," wrote Lépine.

He recommended the centre review all the interventions carried out during this event and to ensure the presence of a living unit manager at all times. He said security guards should also have precise guidelines to follow should this person ever not be present.

In 2022, CBC published a report highlighting numerous issues at Ullivik, including complaints from patients about treatment by security personnel. The centre has also struggled with high staff turnover and allegations of mismanagement.

Rehire social worker, limit duration of stays

Lépine said residents at Ullivik can sometimes stay there for several weeks at a time "and may experience social or cultural adaptation difficulties" given the distance from their community.

He said the position of a social worker, which was cut due to budgetary reasons, must be reinstated to provide support when needed. The presence of a spiritual care worker is also recommended in order to communicate with those who wish to do so.

Lépine said the McGill University Health Centre (MUHC) should also prioritize shortening wait times for treatment for patients from Nunavik to limit the risks associated with a prolonged stay.

Café-Bar Dorval's staff should continue regular training as to not overserve alcohol, Lépine said. While Ullivik has a no-alcohol or drugs policy, it has struggled with controlling the problem.

The coroner recommended bar staff meet with the centre's administration in order to be made aware of the patients' realities and identity and implement concrete steps to help stem the issues.

Last year, in an effort to make the area safer, the city of Dorval installed new pedestrian crossings and new directional signs with three languages on them: English, French and Inuktitut.