Innu man who froze to death in Montreal ‘not solely responsible for his fate,' coroner says

Montreal Gazette

15-05-2025

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Gaps in health-care services, COVID-19 restrictions and a lack of resources for the unhoused all contributed to an Innu man's death in Montreal in 2021, a Quebec coroner has concluded.
Coroner Stéphanie Gamache has put forward 23 recommendations as a result, including that Quebec bolster services for Indigenous people in the health network and better fund resources for the unhoused.
Raphaël 'Napa' André, 51, was found frozen to death in a portable toilet in January 2021, steps away from a homeless shelter that had paused overnight stays due to pandemic restrictions.
'We must express our indignation at the fact that several doors were closed to Mr. André in the last months of his life,' Gamache wrote in her 75-page report published Thursday morning.
'Many people worked with dedication and to the best of their abilities to try to help Mr. André,' she continued. 'However, despite all the efforts made, I found several gaps in the trajectory of care and services until his death.'
A public coroner's inquest into André's death was held last summer, hearing from 51 witnesses over two weeks and leading to Thursday's report.
Originally from the Innu village of Matimekush-Lac John in northern Quebec, André struggled with chronic alcoholism and was a regular at Montreal shelters serving the Indigenous community.
A week before his death, Quebec instituted a province-wide curfew to stem the surge in COVID-19 hospitalizations and the shelter where he was a regular, the Open Door, was no longer accommodating overnight stays.
The inquest heard how, on the day before he was found dead, André visited shelters three times and was treated at the ER of the CHUM hospital in downtown Montreal.
He walked to another shelter after leaving the hospital, but was told by a worker he couldn't stay the night because he didn't want to take a COVID-19 test. He then went back to the Open Door, but was eventually told he had to leave because there were no more overnight stays.
He was found the next morning in the portable toilet. Despite the fact it was only about minus-3 C that night, a pathologist ruled it was hypothermia that killed him. His blood alcohol level was more than four times the legal driving limit.
'Had a door been opened for him, and had he had a warm and safe place to stay for the night, it is clear to me … that he would not have died, even though he was highly intoxicated by alcohol,' Gamache wrote in her report on Thursday.
'It is therefore impossible for me to conclude that Mr. André was solely responsible for his fate.'
Gamache paints a detailed portrait of the years and months leading to André's death in her report, analyzing each of the interactions he had with the health network, police, and homeless shelters.
She questions why no one took charge of him after losing his family doctor in 2020 — despite his many health issues — and how he was allowed to continue slipping through the cracks in his last days.
Gamache notes that she heard several different theories as to why André sought shelter in the portable toilet the night of his death, including that he might have been trying to hide from police given his distrust in authorities and the curfew that was in place.
'Mr. André's last refuge'
'The many hypotheses raised do not change the obvious, which is that this chemical toilet becomes Mr. André's last refuge, since no other place is accessible to him,' Gamache wrote.
She also noted how, a few days after André's death, a shuttle began making the rounds at night to redirect unhoused people to shelters that were open.
While questioning whether the service could have saved André's life, Gamache noted it certainly would have improved his chances at survival. But as the report makes clear, homeless shelters and the health services governing them were scrambling to adapt to the pandemic and the upheaval it brought.
'In the future, we need to ensure that we have a response adapted to the problems of unhoused people in the context of a health emergency,' Gamache wrote.
Gamache's recommendations revolve around five themes. They include the importance of ensuring unhoused people are properly followed in the health network and securing permanent funding for emergency shelters.
Gamache will present her findings at a news conference Thursday.