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The Bordeaux prison, also known as the Montreal Detention Centre, is seen in Montreal on January 24.Christinne Muschi/The Globe and Mail

Lack of proper health care played a role in several detainees’ deaths in recent years at the Montreal Detention Centre, also known as Bordeaux jail, according to coroner’s reports, despite repeated recommendations to improve care and monitoring.

Quebec’s coroners investigate every death occurring in detention centres. A Globe and Mail review of the reports for the past decade at Bordeaux found that, while most deaths resulted from suicide, at least six involved deficiencies in physical health care, including delaying or denying treatment to ill detainees.

Bordeaux was recently under the spotlight when an unlawfully detained young Black man named Nicous D’Andre Spring died after what appeared to be policy violations by staff, according to documents obtained by The Globe. Quebec’s head coroner announced a public inquiry into his death, adding to criminal and administrative investigations.

In the most recent case where lack of care preceded a death at Bordeaux, a 64-year-old detainee complained of abdominal pain for over 10 days before being taken to hospital. Christian Barbier “probably died of fulminant hepatitis” in March, 2021, according to an April, 2022, coroner’s report.

“It would have been desirable for him to be hospitalized more quickly,” coroner Éric Lépine wrote. This could have, if not cured Mr. Barbier, at least “ensured him a less painful and more dignified end of life.”

Mr. Lépine recommended that the detention centre’s management “reassess the quality of the supervision” and the care received by Mr. Barbier, and that an administrative investigation be ordered. This investigation is continuing, according to the ministry of Public Security.

Mr. Lépine was not the first, nor the last one to make such recommendations after deaths at Bordeaux, Quebec’s largest provincial correctional facility, where detainees serve sentences of less than two years or await trial.

“Unfortunately, the same problems continue to arise,” Sandra Lehalle, associate professor at the University of Ottawa’s Department of Criminology, wrote in an e-mail. Correctional services “do not sufficiently incorporate lessons learned from past deaths into their practices” and often do not take into account or act on the coroners’ opinions, she added.

On July 10, 2020, a 44-year-old named Bobby Kenuajuak arrived at the detention centre wearing only underwear but sweating profusely, out of breath even when resting, and wobbling when walking.

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Bobby Kenuajuak, 44, died at Bordeaux prison in 2020.Handout

He “probably died of a malignant arrhythmia” while experiencing alcohol withdrawal, wrote coroner Karine Spénard, in a report dated Sept. 20, 2022. Considering the signs, Mr. Kenuajuak “should have been assessed in the infirmary” upon his arrival, according to the coroner, which “could have prevented his death.” But a manager failed to ensure this was done.

Instead, Mr. Kenuajuak spent the night lying on the floor of his cell, something a correctional officer first noticed on a surveillance round at 11:50 p.m. and eight more times over the next 11 hours.

Another guard noticed past 11 a.m. that Mr. Kenuajuak was already rigid, suggesting that he “probably” died under the first guard’s watch, who should have checked on him, Ms. Spénard wrote.

Her report mentions that Quebec’s Ministry of Public Security internal investigations division recommended that Bordeaux remind a manager and correctional officers of their obligations and take “appropriate measures” toward the officer on duty when Mr. Kenuajuak died.

Mr. Kenuajuak, directed the award-winning 1999 documentary My Village in Nunavik, about his home village Puvirnituq in northern Quebec.

“Bobby was a very kind person” who loved his community, said his sister, Annie Hickey Kenuajuak.

“I’m extremely angry with them and I’m extremely disappointed,” she said of the correctional services’ staff.

On May 20, 2020, detainee Robert Langevin, 72, died of COVID-19 after a positive test on April 29. He was the first Bordeaux detainee to die of the virus, Le Devoir reported at the time.

On May 7, Mr. Langevin was transferred to the infirmary. Almost no notes were added to his medical file between his admission and May 18, when he was transferred to a hospital after experiencing fever and difficulty breathing, according to a coroner’s report.

“It was essential to document the observation and progress notes,” wrote Ms. Spénard, who also filed this report. “It is difficult to know if the outcome would have been different” had this been done, she noted, but worth asking. She recommended that the nursing and medical staff be reminded of good note-taking practices.

On Nov. 29, 2017, detainee Domenico Sciortino, 53, “probably died of acute pancreatitis leading to heart failure,” a natural cause of death, wrote coroner Marjorie E. Talbot. Mr. Sciortino felt nauseous on that day but thought he could wait for an infirmary appointment scheduled the next morning.

He did not make it through the night. His cell, unlike others, did not have a panic button, which “could prevent deaths” when detainees are otherwise unable to ask for help in a timely manner, Ms. Talbot wrote. In her 2019 report, the coroner recommended evaluating the possibility of adding panic buttons to all Bordeaux cells.

On March 28, 2015, detainee Ernesto Alvarez, 44, overdosed on fentanyl, a powerful opioid, and died. Coroner Jean Brochu noted that not all staff members who intervened knew how to perform CPR, knowledge he deemed “essential” because in such events, “minutes count.”

Dr. Brochu recommended that all Bordeaux staff who come into contact with detainees be familiar with resuscitation procedures.

Lynda Khelil, a spokesperson for Quebec’s Ligue des droits et libertés (League of Rights and Freedoms), a human rights advocacy group, said that “there is no accountability for these recommendations, which are themselves completely insufficient.”

These recent deaths highlight long-standing concerns. The Quebec Ombudsperson wrote in her 2018-2019 report that in the previous three years, “more than 20 per cent of the complaints” sent by provincial detainees were related to health care. “This percentage is high,” she noted. The pandemic only exacerbated the problem at Bordeaux because of staff shortages, she wrote in her 2020-2021 report.

In the first incident involving lack of care at Bordeaux noted in a report reviewed by The Globe, Van Duc Tran, 53, was denied treatment in the days leading up to his death, wrote coroner Jacques Ramsay in his 2015 report.

Mr. Tran died from asthma-related complications in March, 2013 after staff misdiagnosed his difficulty breathing as anxiety and then as fake, despite his known condition.

His death was “preventable” and highlights “flaws in the level of care” at the facility, Dr. Ramsay wrote. His recommendations include more staff training and additional evaluations of the detention centre’s health care.

In response to The Globe’s questions, Ministry of Public Security spokesperson Louise Quintin wrote in an e-mail that all but one of the recommendations listed above were either done or not applicable anymore. The addition of panic buttons to all cells, recommended in 2019, is “ongoing,” she wrote.

The only consequence faced by the detention centre’s staff was a five-day suspension for one corrections officer involved in Mr. Kenuajuak’s death.

Recommendations that the detention centre review the quality of care were deemed not applicable because health care at the facility has been overseen by Quebec’s Ministry of Health since April, 2022, Ms. Quintin wrote. The CIUSSS du Nord-de-l’Île-de-Montréal, a regional health centre now responsible for health care delivery at Bordeaux, referred questions back to the Ministry of Public Security.

The number of deaths at Bordeaux is “proportional to what is observed in other detention facilities in Quebec,” Ms. Quintin said.

According to data from the ministry, 132 inmates died in provincial correctional facilities between April, 2017, and December, 2022, excluding Mr. Spring. Among those, 59 died by suicide, two by homicide, 43 from natural causes, and 27 from an “indeterminate cause.” Approximately 4,500 people were incarcerated in these facilities at the end of last year.

Editor’s note: A previous version of this article said Bobby Kenuajuak died in July 2022. In fact, he died in July 2020.