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A Quebec coroner has ruled the hypothermia death of Gilles Duceppe’s 93-year-old mother last January was accidental, but video footage of the woman trying to re-enter the luxury seniors’ residence from the enclosed courtyard where she died shows it was preventable as well.

Helene Rowley Hotte Duceppe, the mother of the former Bloc Quebecois leader, died of hypothermia on Jan. 20, on a morning when it was a bitter minus 35 degrees outside and snowing.

She was drawn outside by what turned out to be a false alarm and was already trapped when Montreal firefighters gave the all-clear to the tower in which she lived and advised residents to stay in their units. Earlier, a carbon monoxide alarm had gone off in a separate tower.

Coroner Gehane Kamel recounted Tuesday that the woman – who was in fine health with the exception of requiring a hearing aid – was visible on surveillance video, but staff did not notice her struggling to get inside, nor did they detect her absence from her apartment.

The death “could have been avoided,” Kamel said.

Having left the Residence Lux Gouverneur building from the nearest emergency exit to her apartment just before 5 a.m., she was captured on video trying to keep warm and get back inside. While her departure set off an alarm, there was no way to open the door from the outside, and there was no doorbell or intercom system.

“We see clearly on the video that Mrs. Duceppe tries to protect herself from the cold, she goes away from the door trying to find her way out of the courtyard, coming back to the door to protect herself from the wind,” Kamel said.

She tried several times to get out of the snowed-in courtyard. On the video, she’s seen walking, moving, sitting down, lying down and trying to warm her hands. Over the minutes and hours, she had more and more difficulty moving around, and Rowley Hotte Duceppe’s last recorded movement on camera was at 11:02 a.m., nearly six hours after she’d become trapped.

She would be found at about 11:40 a.m. after a member of the family alerted staff she was missing.

“She spent more than six hours outside – either near the cameras or in front of the cameras – without anyone noticing she was there ,” Kamel said.

The coroner’s report highlights a number of mistakes by staff and shortcomings in the technology designed to keep the residents safe.

Rowley Hotte Duceppe’s unit was equipped with a motion detector that failed to capture her leaving the apartment in the early morning hours.

A staff member who took over at 8:40 a.m. did not check the video screens. An employee who reset the alarm for the door through which Rowley Hotte Duceppe had exited didn’t look outside to make sure no one was in the courtyard.

The coroner noted a Montreal fire department official was told yes when he asked whether residents from her tower were all accounted for.

Marc-Antoine Cloutier, a lawyer speaking on behalf of the Duceppe family, says the family is not ruling out legal action against the luxury residence and is calling on the provincial government to take action to prevent similar situations in the future.

Cloutier described the situation as a “series of serious mistakes that are very close to what might be called negligence,” lamenting that once an employee sat down at reception at 8:40 a.m., all they had to do was look at the cameras.

Kamel made several recommendations, including providing the residence with an intercom system and doorbells for the emergency exits as well as appointing someone to monitor cameras to ensure residents’ safety.

The coroner said the Residence Lux Gouverneur agreed to a series of short-term recommendations and has already began implementing them.

The residence said in a statement that once the fire alarm went off, the Montreal fire department had control of the buildings and emergency exits. “The safety and well-being of residents is a top priority for management,” it said, offering condolences to the Duceppe family.

Quebec Premier Francois Legault said while there’s no recommendations specific to the government, Seniors’ Minister Marguerite Blais is looking into measures that would ensure such a tragedy doesn’t happen again.

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