Coroner says security measures at Inuit centre need review following deaths of 2 women

The Ullivik lodging centre sits alongside Highway 520 in Dorval. Inuit coming south for medical care stay there between appointments or treatments.  (Khaled Yeddes/CBC - image credit)
The Ullivik lodging centre sits alongside Highway 520 in Dorval. Inuit coming south for medical care stay there between appointments or treatments. (Khaled Yeddes/CBC - image credit)

A Quebec coroner is calling for a review of security intervention measures at the Ullivik lodging centre in Dorval, Que., 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.

In response to the report, Ullivik said it is a place of accommodation where people are free to come and go during the day and it has strong relationships with the local police to "contribute to user safety."

"The well-being and security of residents are central to everything we do at Ullivik," it said in a statement.

"A proactive approach is taken 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."

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 News 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.

Louisa Kuananack is staying at Ullivik as she waits for surgery in a month. She will have to travel between Montreal and Puvirnituq again before her operation, which she has done many times before. She says she was staying at the centre when the two deaths occurred.

"They have to be more careful," she said. "If people are drunk and try to leave, they have to recognize us.… They have to spot us."

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.

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.

The MUHC said it is aware of the report and takes "all coroner reports seriously."

Nearby bar 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.

Tulugak was Levi Kanuayuha's cousin's granddaughter. His brother has been at Ullivik for three years to treat his kidney issues. He says drivers ought to be more careful near the centre and patients should be well supervised.

"Where I come from social services don't help us so much. But all the people from here should have a meeting and make things better.… There should be security around here," said Kanuayuha.

More in-community services needed

Richard Budgell, an assistant professor of family medicine at McGill University, said the report does not go far enough.

"Mrs. Tulugak's death was deeply tragic, she was a young woman with her life ahead of her," said Budgell, who is Inuk from Labrador.

"For this kind of thing to happen twice in a quick succession emphasizes the tragic nature of these kinds of accidents."

He says Ullivik has to work under intense pressure — at least 5,000 patients are brought to Montreal from Nunavik for health care annually, according to data from 2020.

"What that also says is we are not prioritizing the development of broader, more sophisticated services within Nunavik so that Nunavummiut, people living in Nunavik, would be able to access more health services directly in their community," he said.

As comfortable and well-managed as Ullivik can be, Budgell echoed Lépine's conclusion that the isolation makes patients more vulnerable as they are far away from their friends and families while undergoing health treatments.

"Like any of us, when you are sick or injured you want that kind of support from your own family and friends, and people are removed from that kind of support and in situations of greater vulnerability and risk sometimes because of that," said Budgell.