When she showed up at the Ullivik centre in Dorval on the night of August 19, 2022, Mary-Jane Tulugak was heavily intoxicated. A living unit manager should have met her immediately to offer her “help appropriate to her condition.” But after waiting 30 minutes, the young mother of three children instead left in a wheelchair and was fatally struck shortly after on Highway 520.
“The circumstances of these deaths are disturbing and raise questions, many of which will remain unanswered,” we can read in the report by coroner Éric Lépine, dated June 18.
A resident of the village of Puvirnituq on the Hudson Bay coast, Ms.me Tulugak worked for the municipality but was on maternity leave. After injuring her ankle, she was taken to Montreal on July 28, 2022, for surgery.
While waiting for his surgery, Mme Tulugak lived at the Ullivik Centre. This was her first stay. Located not far from the airport in Dorval, the Ullivik Centre accommodates up to 140 patients from the North who are passing through Montreal to receive specialized care. Because while basic care is offered in Kuujjuaq and Puvirnituq, many patients must travel to the city each year to receive care.
PHOTO TAKEN FROM FACEBOOK
Mary-Jane Tulugak
No room
M’s operationme Tulugak would be postponed twice and her surgery would not be until August 18. That same evening, while she was back at the Ullivik centre, the young woman went to the Café-Bar Dorval nearby. She stayed there until closing time at 3 a.m. Police officers found her on the ground not far from the bar shortly after and took her back to the Ullivik centre. Her blood alcohol level was 222 mg/dL, according to the coroner. A concentration that “most certainly caused a weakening of her physical and mental faculties,” he wrote.
According to an internal directive of the Ullivik center, intoxicated people are not allowed access to the rooms. On August 19, 2022, security guards told Mme Tulugak that she could not go up. However, two rooms are available at the reception of the Ullivik center and can be offered to residents who are too intoxicated to go upstairs. A living unit manager must normally assess these cases.
But on the evening of the tragedy, the manager on duty was on break and was never informed of Mr.me Tulugak. “According to the regulations in force, Mr.me Tulugak should have been recommended to the head of the living unit who could have offered her appropriate help for her condition,” it is written.
On the contrary, for 30 minutes, Mme Tulugak moved to the ground floor of the Ullivik centre “without any particular intervention from security officers”. The young mother left the premises around 4 a.m.
Five minutes later, surveillance cameras from the Ministry of Transportation captured Mme Tulugak, in her wheelchair, who was entering Highway 520 at Exit 2. She was driving against the flow of traffic. She wandered for a while on the tracks before being fatally struck by a car taking Exit 2.
Twelve recommendations
The report states that Mr.me Tulugak did not show any signs of psychological distress. In fact, she was “looking forward to returning to her community and seeing her children again.” Several measures were taken following Ms.me Tulugak. Especially since barely 24 hours later, another resident of the Ullivik center, Nellie Niviaxie, lost her life in similar circumstances.
A fence has been put in place to prevent access to Highway 520 near the Ullivik centre. A secure route has also been set up to allow Ullivik residents to walk to nearby businesses.
Coroner Lépine nevertheless issued 12 recommendations. He emphasized that “the specialized health services offered to the Inuit of Nunavik sometimes involve long stays in Montreal, which for some of them take place in a context of vulnerability due to their medical condition and the distance from their home community.” According to the coroner, in this context, it is necessary to avoid “evaluating patient safety solely from the perspective of individual responsibility.”
Me Lépine recommends, among other things, that a living unit manager be available at all times at the Ullivik centre and that specific instructions be given to security agents. He also asks that the position of social worker at the Ullivik centre, which was abolished for budgetary reasons, be reinstated.
The Inuulitsivik Health Centre should also ensure that it provides people who visit the Ullivik centre for the first time with “a minimum of information on security issues surrounding their stay in the city”.
The coroner also addresses Café Dorval. “Several police interventions by the SPVM have taken place in recent years in the parking lot adjacent to this establishment, most of which involved intoxicated persons,” the report states. Me Lépine believes that it would be “useful to regularly remind the staff of this establishment of the rules applicable to holders of alcohol permits, in particular the provision prohibiting the serving of alcohol to a person in a state of intoxication.”
The McGill University Health Centre should for its part “integrate the patient’s place of residence into its assessments of medical treatment priorities.” […] in order to avoid a prolonged stay in the metropolis”.