A coroner’s reports into the deaths of two Nunavik women during their stays at a medical boarding facility near Montreal two years ago include several recommendations to improve the safety of Inuit in the city. Mary-Jane Tulugak, 22, died on Aug. 19, 2022, after she was struck by a vehicle on Hwy.
520. Nellie Niviaxie, 26, died less than 24 hours later after she was struck by multiple vehicles on Hwy. 20.
They were both staying at the Ullivik medical lodging facility in Dorval, Que., which houses Nunavimmiut who travel south for medical treatment. Coroner Éric Lépine announced an investigation into the deaths about a week later.
Those investigation reports were released earlier this month and include information about Tulugak’s and Niviaxie’s deaths as well as 12 recommendations aimed at preventing similar incidents. According to the reports, both women spent the evening at Café-Bar Dorval, about a 25-minute walk away from the centre. The incidents were not related, but the recommendations are the same for both deaths.
On Aug. 19, Tulugak returned from the bar with the help of police around 3 a.m.
and she was left in the care of a security guard because the Ullivik’s manager in charge of the facility at the time was on a break. The security guard did not let Tulugak into her room but instead left her to roam around the common area for 30 minutes until she left and called a taxi. Tulugak was hit by a vehicle at 4:12 a.
m. and later died. Ullivik’s manager was not informed until 3:57 a.
m. that Tulugak had returned and subsequently left. In the early morning of Aug.
20, Niviaxie was at the same bar and left alone at 12:26 a.m. She was spotted 30 minutes later walking on the side of a nearby highway.
She was initially hit by one vehicle, then multiple other vehicles while lying on the road unconscious. At 1:15 a.m.
, police said she had died. The coroner made recommendations for Ullivik centre; Inuulitsivik Health Centre, which provides health services to Nunavimmiut in Montreal; the bar where both women had been before their deaths; Nunavik’s Ungava Inuulitsivik Health Center and Tulattavik Health Center; Montreal police; Makkivik Corp.; Native Friendship Centre; City of Dorval; and McGill University Health Centre.
The recommendations include making sure a manager is available at Ullivik at all times and that the centre review all interventions by security staff; that Café-Bar Dorval continue to train staff in preventing alcohol overconsumption; that Nunavik health officials provide better preparation for patients before they head south; and that southern health providers make sure somebody is there to help Nunavik patients who are struggling, among others. Café-Bar Dorval is owned by Placement Sergakis Inc., a company that manages bars, restaurants and real estate across Montreal.
“We feel very sad and very sorry that this happened,” CEO Peter Sergakis said in a phone interview. The coroner recommended Café-Bar Dorval management meet with Ullivik management to come up with ways to prevent alcohol overconsumption. Sergakis said this has happened, and the two have established a direct line of communication when someone from Ullivik requires a ride from the bar.
“We are going to work together in the future to find solutions,” he said, adding his company has strict rules against over-service of alcohol As for the recommendations for Ullivik, assistant director Yves Lorion said in an email statement that “several measures already in place have been reviewed, improved or implemented since the tragic events.” Lorion said the recommendations align with what the medical boarding home is already doing. “We encourage our Nunavimmiut clients who may be unfamiliar with the realities of the south to seek assistance from our staff,” he said.
Ungava Tulattavik Health Center responded as well to the recommendation to offer information for patients before their departure to Montreal. Spokesperson Nathalie Poirier said in a French email that there is a liaison service in place that takes care of clients going south for treatment. The process includes the chance for patients to ask questions and have them answered in whatever language they prefer.
According to Lorion, the City of Dorval implemented supportive measures such as Inuktitut signage, better road safety and cultural workshops for local police..
