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Marie-Wasianna Echaquan Dubé, eldest daughter of Joyce Echaquan, cries during a rally in Trois-Rivieres, Que., June 2, 2021.

Ryan Remiorz/The Canadian Press

The Quebec coroner conducting the inquest into the hospital death of Joyce Echaquan, the Indigenous woman ridiculed by staff and then neglected as she died, has ended her inquiry with a promise to be unflinching in her final report.

Géhane Kamel, the coroner presiding over the inquest, said she hopes the report will form the “foundation of a new social pact that will bring us to say, ‘Never again.’”

She had a message for Carol Dubé, Ms. Echaquan’s husband, and her family. Earlier this week, Mr. Dubé accused hospital staff and managers of lying about the chain of events that led to the death of his wife and mother of seven. “The story you have left me to tell my children about the way their mother left us is based on lies and nightmares,” Mr. Dubé said. “Would anyone listening to me accept to tell their children this story?”

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Senior staff deny knowing racism a problem at Joliette hospital

Reform needed to reduce Indigenous patients’ fear of health system, surgeon tells Echaquan inquiry

In her final statement of the inquest, Ms. Kamel suggested another story for Mr. Dubé: “Tell your children that a small reconciliation revolution started thanks to their mother.”

After three weeks of testimony, the inquest has exposed in grim detail Ms. Echaquan’s racist and neglectful hospital treatment, and the insecurity of her fellow Atikamekw and other Indigenous people when facing the medical system.

Carol Dube, left, husband of Joyce Echaquan, is hugged by a supporter during a rally.

Ryan Remiorz/The Canadian Press

About a thousand Indigenous people and their supporters gathered outside the Trois-Rivières courthouse Wednesday to mark the end of the inquest with marching, dancing and singing.

Ms. Echaquan’s case rose to international prominence after she broadcast on Facebook Live two staff members showering her with racist abuse as she writhed in pain in a hospital bed shouting, “I’m in pain, I’m in pain, I’m going to die.”

An hour later, Ms. Echaquan’s daughter recorded a second, private video of Ms. Echaquan showing no visible signs of life while a nurse trainee did little to help her. The patient waited at least 17 minutes for an attempt to revive her and she was pronounced dead about an hour later. She had fluid in her lungs stemming from chronic heart failure that accelerated suddenly while hospital staff did not treat her.

Much of the inquest concentrated on systemic racism in the hospital system, a controversial term in Quebec. Premier François Legault refuses to acknowledge the existence of systemic racism, which is a form of racism embedded in society’s rules and institutions, such as hospitals.

“It’s vital to start by recognizing racism and calling it what it is, with the right words,” Ms. Kamel said in her departing comments.

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The inquest heard that Ms. Echaquan could have survived with proper medical attention, but the hospital let her down through a combination of misdiagnosis, poor staffing and neglect.

Ms. Echaquan’s complaints of pain were dismissed and greeted with racist comments, and then misdiagnosed as withdrawal from painkillers, and then misdiagnosed as a psychotic episode. She was restrained and sedated.

Hospital administrators said a nurse trainee should not have been in charge of a dozen patients as qualified nurses went for lunch, while arguing with union representatives about whether the emergency room was understaffed. Some managers admitted the hospital had a civility problem while denying that included chronic racism.

Some current staffers denied ever hearing racism among colleagues at the hospital while others and ex-workers said it was common. An Indigenous outreach worker described how she worked at the hospital for two years while never being recognized as part of the care team.

The names of several staffers who mishandled Ms. Echaquan’s case that day are covered by a publication ban.

But for the two videos and the frank testimony of Ms. Echaquan’s roommate who was appalled by the treatment she witnessed, it’s unlikely Ms. Echaquan’s death would have had a hearing with the coroner, family lawyer Patrick Martin-Ménard noted.

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For the region’s Indigenous leaders who also testified and made recommendations, the root of the failure was obvious: The Canadian medical system systematically dismisses Indigenous health issues and dehumanizes Indigenous patients.

“She fell through the holes of successive security nets. All the holes were aligned,” said Atikamekw Nation Grand Chief Constant Awashish. “Why were they aligned like that? Because she was tagged as a First Nations woman who didn’t merit all the tools of the medical system, including listening and compassion.”

Paul-Émile Ottawa, Chief of the Atikamekw of Manawan, told the inquest his people feel a sense of collective guilt that Ms. Echaquan died at the hospital. He spoke at length about the insecurity his people feel every time they go to the hospital.

Speaking for Ms. Echaquan’s family, Mr. Martin-Ménard noted Ms. Echaquan’s cardio-respiratory crisis took place in an emergency room of a regional hospital. “She would have had better odds if it had happened on the street,” where an ambulance crew might have saved her, he said. “It’s revolting.”

Mr. Martin-Ménard emphasized the role racism plays in systemic barriers to care, and the denial and deflection players in the system still hide behind. “We had an orderly tell us the racist words were used in a benevolent fashion and a nurse who thought she did nothing wrong but got fired for politics,” he said. “This reflects a wider culture that has to change.”

Most of the people who participated in the inquiry in the final recommendation stage delivered similar calls to action: better staffing and stricter rules about the role of nurse trainees in care settings; more education for hospital workers about Indigenous people; more Indigenous workers in hospitals, including in outreach and translation services to guide Indigenous people through the system; and simplified complaints processes with staff dedicated to accompanying Indigenous people through the process.

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Many of the recommendations were previously part of a statement of principles drafted among the Atikamekw, other Indigenous groups and Mr. Dubé and his family, called “Joyce’s Principle.” The document calls for equitable treatment of Indigenous people in the health system.

Among the first items on the 16-page statement, which was repeated several times at the inquest, was a call for Mr. Legault to recognize that systemic racism exists in Quebec. Mr. Legault’s government has refused to accept Joyce’s Principle because of its use of the term. Ms. Kamel has not announced a date for her final report, but it is likely to take several months.

With a report from The Canadian Press.

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