MONTREAL -- The inquest into the death of Joyce Echaquan concluded Wednesday with coroner Gehane Kamel promising her final recommendations would be "honest" and form the foundation of a social pact declaring "never again."

The coroner said there was a duty to rewrite the story of Echaquan, a 37-year-old Atikamekw mother of seven who filmed herself on Facebook Live as a nurse and an orderly were heard making derogatory comments toward her shortly before her death last September at a hospital in Joliette, Que., northeast of Montreal.

Shortly after the hearings ended in Trois-Rivieres, Que., a large march in memory of Echaquan began making its way to the courthouse where the inquest was held, with local police estimating the crowd at more than 1,000 people.

The inquest heard that Echaquan died of excess fluid in the lungs likely caused by heart failure, but doctors had wrongly diagnosed her as suffering from opioid withdrawal when she arrived complaining of severe stomach pains.

Lawyers representing several parties taking part in the inquest made final arguments to Kamel, who is tasked with drafting recommendations to avoid a similar death.

A lawyer representing the regional health board said it recognizes there is bias and discrimination toward Indigenous patients among staff, whether it's conscious or not, and it is ready to change the situation.

The lawyer representing the Atikamekw nation and the band council in Echaquan's community of Manawan, Que., about 250 kilometres north of Montreal, said the numerous failings in the treatment she received were related to systemic racism in the health-care system.

Jean-Francois Arteau decried a lack of accountability and noted evidence that Echaquan was ignored by staff, surmising she would still be alive if she weren't Indigenous.

Patrick Martin-Menard, lawyer for the Echaquan family, told the inquiry it was important to remember Echaquan as more than someone seen suffering in a widely circulated video.

"She was devoted to her family and had all sort of plans," Martin-Menard said. "She had her life before her, and I think it's important to see Ms. Echaquan from this vantage point and not simply as a patient."

In a closing message, Kamel thanked those who participated in a process that included difficult moments. She addressed Echaquan's family and in particular her husband, Carol Dube, who'd asked Tuesday how he would explain to his children their mother's death.

"To your children, you will have to tell them the small revolution of reconciliation started with their mother," Kamel said.

-- This report by The Canadian Press was first published on June 2, 2021.