Quebec coroner calls on Inuit centre to review safety measures following death of two Inuuk women

A Quebec coroner is asking the Ullivik health centre in Dorval to review all security intervention measures after two Inuuk women who were staying there were killed on separate Montreal highways within a 24-hour period.

In his report, coroner Éric Lépine ruled the death of one of the women as accidental and issued a total of 12 recommendations.

Mary-Jane Tulugak and Nellie Niviaxie were staying at Ullivik after travelling south from northern Inuit communities for medical reasons.

Lépine recommended that Ullivik ensure the presence of a living unit manager at all times. Moreover, he said the centre should hire a social worker and spiritual care worker to help and support residents who request it.

"It would also be helpful to provide specific instructions for security guards to follow when the [living unit manager] is temporarily absent from their post," the coroner wrote.

Most residents of Ullivik are from small northern communities, and when they first arrive in the south, they may experience difficulties with social and cultural adaptation.

The lodging centre was opened in Dorval in 2016.

According to the report, on Aug. 19, 2022, Tulugak from Puvirnituq was captured on surveillance cameras heading down Highway 520 in a wheelchair before being struck by a vehicle.

Once police arrived on the scene, they immediately began cardiopulmonary resuscitation (CPR). Paramedics continued administering resuscitation manoeuvres but ceased when vital signs were completely absent. Tulugak was subsequently pronounced dead by a doctor.

Less than 24 hours later, the Surete du Quebec reported that Niviaxie, 26, from Umiujaq, had died after being struck by multiple vehicles on Highway 20.

"It would be useful, particularly for those who are on their first stay, to receive a minimum of information before their departure on the security issues surrounding their stay in the metropolis," Lépine wrote.

"This information should be transmitted in their mother tongue to ensure that they are properly understood. It is up to Ullivik to establish, in collaboration with health centres and CLSCs, an effective way to reach them and adequately inform them."

A year after the deaths, two new pedestrian crossings were installed along with other measures to secure the transit corridor for those at Ullivik so they could access commercial hubs more safely.