Homeless Innu man died of hypothermia, but Quebec coroner says system failed him

A Quebec coroner looking into the death of Raphaël "Napa" André, a homeless Innu man whose body was found inside a portable toilet in Montreal in January 2021, during the COVID-19 pandemic, concluded his death was preventable. 

In a report made public on Thursday, Coroner Stéphanie Gamache wrote that it was impossible for her to conclude "that Mr. André was solely responsible for his fate." 

The 51-year-old from the Innu community of Matimekush-Lac John died due to hypothermia in a context of severe alcohol intoxication, but Gamache wrote that there were systemic failures that contributed to his death as well. 

"If a door had been opened to him and if he had had a heated and safe place to stay for the night, it is clear to me ... that he would not have died, even if he was heavily intoxicated due to alcohol," she said. 

André's body was found steps away from a shelter on Parc Avenue that had been closed by public health officials because of plumbing problems and a COVID-19 outbreak.

Quebec had also imposed a nighttime curfew to curb the spread of the virus.

How he came to seek refuge inside a public toilet will likely never be known, but several hypotheses were put forward, Gamache said. 

Gamache said it may have been due to "hide and die" syndrome, which occurs in the final stages of hypothermia, or maybe he was fearing an interaction with police for being outside after curfew. 

In her 75-page report, Gamache noted several gaps or failures in terms of André's care and access to services in the months preceding his death.

"In memory of Mr. André, of his life and his battles, I invite you to read the document, in spite of it's length," Gamache said during a Thursday news conference to present her findings. 

"His death took place in inhumane conditions," she continued, adding it should serve as a wake-up call for society to transform the way vulnerable people are cared for, supported and protected. 

Recommendations centre on 5 themes

The 23 recommendations issued in her report are aimed at preventing another death in similar circumstances. 

Those recommendations centred on five themes identified by Gamache as ways to strengthen the safety net she says is  necessary to help people experiencing homelessness regain their rightful place in society.

First she stressed the importance of ensuring centralized monitoring for the homeless population who consult various facilities within the health-care network.

Gamache said that André's situation was extremely complex but emphasized the complexity of his situation was not unique. 

What characterized him, however, is the fact that he sought help for alcohol use on numerous occasions and at various health facilities in Montreal. 

His medical file, over a two-year period, is more than 4,000 pages long, Gamache said. 

Each consultation period is marked by different care challenges associated with André's overall health, including his precarious living situation, significant alcohol dependence and a frontal lobe disorder that can cause significant behavioural problems.

She said various blind spots in the health-care network and communication issues may have been the root of an unco-ordinated response. 

Despite many actors in the system providing offers of timely help, Gamache said there was no one person or entity with knowledge of André's file charged with following up or co-ordinating treatment. 

'Proud of his culture and community,' coroner says

The recommendations also focused on the need to develop facilities that can accommodate clients who are intoxicated and have acquired brain injuries.

Gamache noted the absence of an evaluation to determine André's ability to consent or refuse medical help in the last months of his life, when he expressed a difficulty in coping with his problems.

Gamache underscored the need to put cultural safety at the heart of initiatives to help people experiencing homelessness.

"He was proud of his culture and community," Gamache said of André. She pointed to periods in his journey when he was able to express himself through art projects that integrated his origins.  

The absence of culturally safe services represented additional challenges in André's treatment and Gamache recommended more training for health professionals. 

Gamache said it could help workers build trust and stronger ties with those they are trying to help.

The coroner cited data from 2022, that indicates that while Indigenous people make up less than one per cent of Montreal's population, they represent close to 13 per cent of the city's "visible homeless."

The fourth theme delves into the particular context of the COVID-19 pandemic. Gamache said the specific needs of vulnerable populations, such as those experiencing homelessness, need to be considered and taken into account when making emergency decisions. 

Lastly Gamache pointed to the need for permanent funding for resources that provide emergency shelter. 

Gamache's report follows public inquiry hearings that were held last year and included the participation of 51 witnesses.

Among them were Réal McKenzie, chief of the Innu community of Matimekush-Lac John, as well as André's brother, sister-in-law and mother who, Gamache said, travelled from their community to testify. 

Gamache expressed her gratitude for their testimony and extended her condolences to the family and community.