
Death of homeless Innu man found in portable toilet was preventable, says Quebec coroner
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 "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.
His 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.
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.
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 our society.
First she stressed the importance of ensuring centralized monitoring for the homeless population who consult various facilities within the healthcare network.
She also focused on the need to develop facilities that can accommodate clients who are intoxicated and have acquired brain injuries.
Gamache also underscored the need to put cultural safety at the heart of initiatives to help people experiencing homelessness.
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 between May 13 and June 10, 2024, 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, traveled from their community to testify.
Gamache expressed her gratitude for their testimony and extended her condolences to the family and community.
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