Description
Consider Joyce Eshaquan or Brian Sinclair’s stories for this reflection, share more about how you would be a change agent in these systems. Within both reports it was noted that racism was an influencing factor. In this hypothetical reflection, where there are no limitations to your creativeness (meaning unlimited $$, staffing, time, etc.) You are a part of management that has been tasked with ensuing that this doesn’t happen again. What would be your plan (consider outlining types of educational topics, or types of programs would you like to implement? What types of programs have you seen before). I’ve attached the final reports to their investigations- I would say if you need some inspiration have a look at the recommendations. Questions to consider:How would do relate the client’s story? What feelings do you have as you consider doing this work? How has this story changed your perspective on the Canadian Healthcare system? If so, how?If you were in charge what would you do to educate/support your staff?What safety measures would you put in place for Indigenous clients?
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Investigation Report
Law on the investigation of the causes and circumstances of death
FOR THE PROTECTION OF HUMAN LIFE
concerning the death of
Joyce Echaquan
2020-00275
Me Géhane Kamel
Delta 2 Building
2875 Laurier Boulevard, Suite 390
Quebec City, Quebec, G1V 5B1
Telephone: 1 888 CORONER (1 888 267 6637)
Fax: 418 643 6174
www.coroner.gouv.qc.ca
Table of contents
INTRODUCTION ……………………………………………………………………………………………. 3
IDENTIFICATION OF THE DECEASED …………………………………………………………… 3
CIRCUMSTANCES OF DEATH ……………………………………………………………………….. 3
EXTERNAL EXAMINATION, AUTOPSY AND TOXICOLOGICAL ANALYSIS ………. 3
ANALYSIS …………………………………………………………………………………………………….. 4
THE FACTUAL OUTLINE ……………………………………………………………………………….. 4
The Sûreté du Québec investigation ……………………………………………………………… 4
Mrs. Joyce Echaquan……………………………………………………………………………………. 4
Care by the Centre hospitalier de Lanaudière ……………………………………………….. 5
MY FINDINGS ……………………………………………………………………………………………….. 7
Overworked staff ………………………………………………………………………………………….. 14
Training and meeting the other ………………………………………………………………………. 15
The social pact …………………………………………………………………………………………….. 18
CONCLUSION …………………………………………………………………………………………….. 20
RECOMMENDATIONS …………………………………………………………………………………. 20
ANNEX I ……………………………………………………………………………………………………… 22
THE PROCEDURE ………………………………………………………………………………………. 22
ANNEX II …………………………………………………………………………………………………….. 23
LIST OF EXHIBITS ………………………………………………………………………………………. 23
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INTRODUCTION
On September 28, 2020, Coroner André Cantin takes notice of the death of Mrs. Joyce
Echaquan.
Mrs. Joyce Echaquan died at the Centre hospitalier de Lanaudière following unsuccessful
resuscitation manoeuvres. Questions were raised about the quality of the care received by the
patient and the inappropriate comments made about her.
On October 6, 2020, the Chief Coroner of Quebec, Me Pascale Descary, ordered a public
enquiry into the death of Mrs. Joyce Echaquan, which occurred in Saint-Charles-Borromée on
September 28, 2020. I have been appointed to preside over this enquiry, to shed light on the
causes and circumstances surrounding this death, to identify the contributing factors and to
make recommendations, if any.
On April 28, 2021, Dr. Jacques Ramsay, Coroner, was appointed to act as an assessor at this
Inquest.
IDENTIFICATION OF THE DECEASED
Mrs. Joyce Echaquan was visually identified by a relative who was at her bedside at the
hospital.
CIRCUMSTANCES OF DEATH
An investigation report from the Sûreté du Québec’s Major Crime Section indicates that on
September 26, 2020, Mrs. Joyce Echaquan was transported by paramedics to the Centre
hospitalier de Lanaudière. Mrs. Echaquan had been suffering from stomach pains in the form of
stabbing pain for a fortnight; episodically at first and then in a crescendo, for the past 24 hours.
During her hospitalisation on September 28, 2020, Mrs. Echaquan suffered a cardiorespiratory
arrest and resuscitation manoeuvres were initiated by the medical staff, without result. She was
pronounced dead at 12:44 p.m.
The Sûreté du Québec handled this case in assisting the coroner.
EXTERNAL EXAMINATION, AUTOPSY AND TOXICOLOGICAL ANALYSIS
An autopsy was performed on September 29, 2020 at the McGill University Health Centre. In his
report, the pathologist notes the presence under microscopy of the heart, of characteristic cells,
named Aschoff’s cells, grouped in clusters forming Aschoff’s bodies. This is a very suggestive
(pathognomonic) sign of a rheumatic disease, in this case chronic and recurrent (active)
rheumatic carditis. This diagnosis was confirmed by a cardiopathologist at the Centre hospitalier
de l’Université de Montréal.
The heart is large and his ventricles are dilated, suggesting cardiac malfunction. This is
consistent with Mrs. Echaquan’s medical history, which includes episodes of heart failure that
fluctuate over time. Finally, the pathologist notes engorged and very heavy lungs (over 2000 g),
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suggesting that heart failure could be the cause of death. The presence of a defibrillator was
noted.
The Laboratoire de sciences judiciaires et de médecine légale conducted the usual toxicological
analyses on October 7, 2020. The tests revealed the presence of diphenhydramine,
acetaminophen and morphine, all within a therapeutic threshold. Traces of lorazepam, cannabis,
duloxetine and metoprolol were also detected.
On 7 January 2021, I requested an additional analysis to contextualize the intake of haloperidol
(Haldol®) (an anti-agitation medication). Again, the concentration found in the blood was at a
level considered as therapeutic.
ANALYSIS
The death of Mrs. Joyce Echaquan and the public enquiry that followed have caused deep
distress to her family and to the Atikamekw community of Quebec. It also harshly confronted
Quebec society as a whole.
In this regard, because of the very high emotional toll associated with this tragedy, it is
imperative to mention that my analysis is in no way intended to determine the criminal or civil
liability of the health care institution or of any individual. Rather, the entire process is intended to
seek the truth about the circumstances surrounding Mrs. Echaquan’s death and the factors that
contributed to it.
The analysis of the events leading up to the death (the factual framework) can be divided into
three factual segments: the conclusions of the Sûreté du Québec investigation, Mrs. Echaquan’s
medical history, and the treatment by the Centre hospitalier de Lanaudière (also known as the ”
Hôpital de Joliette”).
THE FACTUAL OUTLINE
The Sûreté du Québec investigation
On September 30, 2020, Mrs. Echaquan’s file at the Sûreté du Québec’s Major Crime
Investigation Service in Mascouche was seized from them, following the transfer of
responsibility from the investigation office of the Joliette MRC.
During the investigation and based on the information obtained from the various witnesses, the
Sûreté du Québec concluded that no criminal offence had been identified. Consequently, the file
was not submitted to the Director of Criminal and Penal Prosecution.
Mrs. Joyce Echaquan
Mrs. Echaquan is a 37-year-old mother of seven children, of whom she was very proud. She is
described by her partner and family as a loving mother, a religious person and a person
dedicated to her community. She loved life and, had it not been for her health problems, would
probably have had more children.
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Mrs. Echaquan was known to have a significant medical history, including diabetes and severe
non-ischaemic cardiomyopathy resulting in heart failure with an ejection fraction (EF)1
fluctuating at very low values as monitored over the years, i.e. between 38% and 10%. An
acetaminophen intolerance was also noted.
Care by the Centre hospitalier de Lanaudière
Mrs. Echaquan was hospitalised at the Centre hospitalier de Lanaudière between the evening of
September 26, 2020 and the early afternoon of September 28, 2020, when she was pronounced
dead.
I retained the services of Dr. Alain Vadeboncoeur, an emergency physician at the Montreal
Heart Institute, as an expert. His expertise was not contested by the parties. Dr. Vadeboncoeur
enabled us in particular, to determine the trajectory of the medical stay and to specify the cause
of Mrs. Echaquan’s death.
On September 26, 2020, at approximately 11:00 p.m., Mrs. Echaquan arrived by ambulance at
the Centre hospitalier de Lanaudière. The triage nurse’s initial assessment mentions in her
progress note that Mrs. Echaquan had been complaining of intermittent stabbing epigastric pain,
non-radiating, accompanied by palpitations and dyspnea (orthopnea) for the last two weeks.
The pain is said to be constant at 10/10 since the previous afternoon. She also suffers from
nausea and food vomiting after meals and has been eating and hydrating very little for the last
two weeks.
Upon arrival, and in order to rule out a coronary syndrome, which can sometimes manifest itself
as epigastric pain, an electrocardiogram and a cardiac enzyme test are ordered. These tests
are normal. The presumptive diagnoses retained are therefore epigastric pain with a gastric
appearance despite an unremarkable gastroscopy just a few weeks ago, and anaemia. Her
admission diagnosis was a recently exacerbated microcytic (small red blood cells) iron
deficiency anaemia (haemoglobin down from 107 to 81 g/L within a month) and epigastric pain
of an unknown cause. A referral was made to the on-call gastroenterologist and Mrs. Echaquan
was kept under observation. The gastroenterologist planned to do a colonoscopy the next day
to ensure that the cause of the anaemia was not in the large intestine. To do this, the
anticoagulant is stopped and a bowel preparation is given. For pain, the analgesia is adjusted.
On September 27, 2020, the gastroenterologist saw Mrs. Echaquan again, as she was showing
signs of agitation. A possible withdrawal from narcotics and cannabis was mentioned, but no
real use prior to the episode could be demonstrated.
Mrs. Echaquan reportedly said that she had taken medication and been prescribed morphine for
similar pain in August of 2019. An antiemetic (Maxeran®), a benzodiazepine (Ativan®),
acetaminophen and an opioid (morphine) were prescribed and administered to reduce nausea
and symptoms associated with withdrawal and pain.
1 The ejection fraction refers to the ability of the heart to eject a certain percentage of blood present in its
cavity.
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The gastroenterologist scheduled the colonoscopy for the next day. In order to determine
whether there was indeed a possible disorder related to drug use or withdrawal, a request for a
consultation was sent to the Joliette Addiction Rehabilitation Centre. This evaluation, as
reported to the doctor on September 28, 2020, concluded that the symptoms described by Mrs.
Echaquan were not related to physical withdrawal from opioids or stimulants.
Also on the afternoon of September 27, 2020, instead of a nurse, a candidate for the practice of
nursing (CPNP) was in charge of Mrs. Echaquan. Although the diagnosis was uncertain at best,
the nursing staff presented Mrs. Echaquan as a patient in withdrawal.
At about 8:00 p.m., the gastroenterologist saw Mrs. Echaquan again , as she was agitated and
complained of generalized pain. Despite the medication, the agitation was not controlled. Fourlimb restraints and a lap belt were applied. Close monitoring was prescribed. At 10:10 p.m., Mrs.
Echaquan was calmer and the restraints were removed. She remained calm until the morning.
On September 28, 2020, at about 7:40 a.m., a patient who is on a neighbouring stretcher asks
Mrs. Echaquan if she can borrow her mobile phone to reach her son’s school. Mrs. Echaquan is
cordial and the two women talk for a while.
At 9:53 a.m., Mrs. Echaquan exhibits agitation and generalized discomfort. She was given 1 mg
of Ativan®. At 10:10 a.m., Mrs. Echaquan screams and falls, initially described as intentional by
the nursing staff with probable cranial impact. This fall, according to the testimony heard, was
more likely to be accidental, due to a sudden movement of Mrs. Echaquan on his stretcher. The
doctor was informed of the situation. She prescribed a dose of Haldol ® 5 mg intramuscularly
and, if the Haldol ® was not effective, restraints would be used. Mrs. Echaquan was moved from
the stretcher to a cubicle with an anteroom and toilet. The Haldol® is administered at 10:25.
Sometime between 10:35 and 10:45 a.m., Mrs. Echaquan films herself with her mobile phone
and posts the video in real time on the Facebook social network. Two members of the nursing
staff were with Mrs. Echaquan at the time. It is understood from the video that Mrs. Echaquan
fell off her stretcher again. Denigrating words are spoken by the nursing staff. She was put back
on the bed, the intravenous infusion was reinstalled, and then restraints were applied, first to all
four limbs, before the abdominal belt was installed. The video is made without the knowledge of
the staff on site, except at the very end, and lasts 7 minutes and 12 seconds.
At 11:22 a.m., close monitoring was ordered. However, despite several requests to do so by the
CPNP, who had been given responsibility for patient Echaquan, the orderlies were unable to
carry out this monitoring. The CPNP therefore carried out visual surveillance through the cubicle
window until 11:35 a.m., at which time Mrs. Echaquan’s condition deteriorated. The CPNP
admitted that there was a discrepancy between the notes in the file and the actual surveillance,
as it was completely overwhelmed by the events, which were compounded by a particularly
busy day and several other users under its responsibility requiring significant surveillance.
At this point, Mrs. Echaquan is unresponsive and her pulse is barely perceptible at best, despite
the fact that the medical record shows 70 beats per minute. She is hardly awake, her pulse is
reportedly present and her breathing is regular. What is certain, however, is that from 11:39 and
onwards, there is no longer anything regular about her breathing, as evidenced by a second
video broadcast in real time on Facebook by her daughter when she arrives at her mother’s
bedside. This broadcast lasts 10 minutes and 49 seconds and is recorded between 11:39 and
11:49.
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At 11:49 a.m., the CPNP belatedly notes that Mrs. Echaquan is unresponsive to pain and
notifies the doctor. At 11:45 a.m., the vital signs indicated were “blood pressure 57/35, heart rate
77 beats per minute, oxygen saturation 90% on room air. A transfer to the resuscitation room is
requested by the CPNP and the doctor is notified. The room where Mrs. Echaquan is located is
equipped to perform resuscitation. There was a delay before the transfer because the room had
to be cleaned according to the rules applicable in the context of the health crisis related to
COVID-19. At 11:56 a.m., she was transferred to the resuscitation room: Her breathing was
shallow, with six breaths per minute, and there was no verbal response. The doctor was at the
bedside and the four-limb restraints and lap belt would be removed. At 11:58 a.m., the cardiac
monitor indicated an asystole. Resuscitation is initiated. Resuscitation was carried out according
to the established procedures, but to no avail, since death was declared by the doctor at 12:44
p.m.
MY FINDINGS
I have listened carefully to all the evidence and, although my investigation must focus on
detailing the cause of death and establishing the circumstances, I cannot ignore the context in
which the death occurred.
More than 44 factual witnesses were heard. During the testimony of the nursing staff, divergent
and sometimes contradictory versions were told. It is in this particular context that I had to base
my observations.
As soon as she arrived at the Centre hospitalier de Lanaudière, Mrs. Echaquan was quickly
labelled as a narcotics addict and, based on this prejudice, her calls for help were unfortunately
not taken seriously. For example, during her stay at the same hospital in August of 2020, Mrs.
Echaquan cries a lot and complains that she is not believed when she expresses her pain. The
doctor’s note is eloquent as it states “she is dissatisfied and has a tendency to manipulate”.
When she was hospitalised in September of 2020, once again, this label of drug dependence
followed her throughout her stay and guided the actions of the nursing staff until her death. The
medical staff even referred to alcohol withdrawal, which constitutes erroneous information. The
evidence heard during the hearing also showed that Mrs. Echaquan only consumed narcotics
that were duly prescribed and in quantities insufficient to create a dependence. At the time of
her admission to the emergency room, no Medication Reconciliation (MedRec) indicating the
medications that had been prescribed to Mrs. Echaquan was completed. A completed MedRec
would have been an essential working tool to enable the treatment team to properly document
Mrs. Echaquan’s pharmacology and to act accordingly.
When questioned in turn during the hearings, no doctor or staff member of the Centre intégré de
santé et de services sociaux (CISSS) de Lanaudière was able to tell us what Mrs. Echaquan’s
diagnosis of narcotics dependency was based on. Nor will they be able to inform us of the
clinical basis on which this diagnosis is established (apart from the notes in the previous
medical file, which date back a few years and have not been reassessed). In the testimony of
the gastroenterologist, he will admit that the term narcotics addiction may induce a bias in
people’s minds. A conversation also allegedly took place between Mrs. Echaquan and another
doctor at the hospital. This conversation is poorly documented in the medical file and leads us to
believe that Mrs. Echaquan was uncomfortable being relieved with morphine. Indeed, Mrs.
Echaquan criticized the health care providers for never resolving her pain and simply sending
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her home with painkillers. This is the most likely theory, given the side effects of her last
hospitalizations.
When discussing the various diagnoses, the doctor usually uses the question mark when raising
an untested hypothesis. It is therefore important, especially for other doctors and nursing staff,
to avoid jumping to conclusions, as seems to have been the case with Mrs. Echaquan. A
hypothesis must remain a hypothesis until it is validated.
This is the case when the gastroenterologist reports withdrawal due to lack of medication or
cannabis use. Mrs. Echaquan reportedly said she had taken medication. During the day, he
prescribes morphine and Ativan® and requests that she undergo a colonoscopy the next day.
He indicated that she could be discharged afterwards.
In this sense, the consultation with the Addiction Rehabilitation Centre on September 28, 2020,
is indicated since it aims to confirm or refute the diagnostic hypothesis. It should be recalled that
this evaluation concluded that the symptoms described by Mrs. Echaquan are not related to
physical withdrawal from opioids or stimulants.
The day before, on September 27, 2020, at 2.17 a.m., the nurse notes: “advised [sic] patient to
calm down and wait for medication to take effect [sic] […] agitated on stretcher, crying +++, lyre”.
When questioned about her choice of words, the nurse told us that we should rather translate
this as : “I understand your pain, Madam”. The rest of the night was particularly calm.
At 2:18 p.m., Mrs. Echaquan was questioned by the nursing staff about her consumption. It is
stated: “Says she uses pot 3 times a day and more, says she has never had withdrawal
symptoms. Blames nausea again”.
At about 5 p.m., the gastroenterologist is called on his pager by the nurse. The nurse’s note
states: “…patient has had an episode of palpitations and wants to know if he can prescribe a
drug for withdrawal”. Although the electrocardiogram taken earlier showed a sinus rhythm which
turned out to be normal, her palpitations should probably have prompted greater caution in
taking care of Mrs. Echaquan. The medication prescription was also transmitted.
At 7.20pm, Mrs. Echaquan said that she felt unwell, that she was having palpitations again and
that she did not want to die.
At around 7.45 p.m., Mrs. Echaquan got up from her stretcher and found herself on the ground.
She mentions feeling dizzy. She got up with the help of three staff members. However, no
incident or accident report was completed at that time, and no assessment of the pain was
made following the fall.
At 19:55, it is noted that Mrs. Echaquan is “cooperating but [is] very theatrical”. The words set
the tone of the care.
At 20:39, Mrs. Echaquan is agitated. She is placed in restraints. A private orderly service was
present at her bedside. At 9:39 p.m., still in restraints, the fluid intake protocol for the
colonoscopy was started. At 10:10 p.m., the restraints were removed.
Staff also weighed Mrs. Echaquan when she arrived at the hospital. She was weighed again on
September 28, 2020. She weighed 92.2 kg, which is surprising since the day before she
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weighed 87.09 kg. She would have gained 5.2 kg in a few hours. The doctor in charge of
hospitalizations in family medicine, justified this error by a reference weight recorded the day
before, and therefore not real, which is questionable at the very least.
On September 28, 2020, at 8:45 a.m., the gastroenterology resident also saw Mrs. Echaquan,
who had tremors, but these did not necessarily seem credible. When questioned about her
medical notes, including the fact that she indicated that the patient was narcotics dependent
according to the patient’s partner to whom she had not spoken to, and the fact that she had
taken the trouble to indicate that Mrs. Echaquan had seven children, the resident was not very
forthcoming. There is every reason to believe that the resident also drew on the previous notes
and also jumped to conclusions too quickly.
In the testimony of the doctor in charge of hospitalizations in family medicine, they explained
that the restraint measures were applied at Mrs. Echaquan’s request because she starts
screaming and getting agitated when she is in withdrawal and no longer feels like herself. I
would like to express my doubts concerning this allegation, as it seems absurd to me to imagine
a patient asking for restraints.
It should be recalled that the policy on the exceptional application of control measures
(restraints, seclusion and chemical substances), adopted on January 28, 2019 by the institution,
provides, among other things, that chemical substances, restraints and seclusion must be
considered only as a control measure and only as a last resort. In Mrs. Echaquan’s case, we
note that she was mechanically and chemically restrained and isolated without constant
supervision. Moreover, the same policy requires that a record be kept of the use of control
measures. This restraint was not documented on the form provided. At no time were alternative
measures offered to alleviate Mrs. Echaquan’s fears, such as the obvious and simple option of
having a member of the Atikamekw community stay at Mrs. Echaquan’s bedside. However, this
idea of cultural accompaniment never crossed the mind of any member of the hospital’s
caregiving community, despite the availability and presence in due form of an Aboriginal liaison
officer. In doing so, the choice of restraint, supposedly required by Mrs. Echaquan herself, was
certainly not an optimal solution in the circumstances.
At around 9:50 a.m., Mrs. Echaquan becomes agitated, screams and moans. The justification
for withdrawal was again mentioned. Shortly afterwards, she fell, which a witness first described
as intentional, but then changed their mind; the fall could have been accidental. The notes in the
medical file still state that “she is theatrical”. A few witnesses admitted that colleagues thought
she was acting at times during the morning. Mrs. Echaquan has clearly been labelled a difficult
patient. It is a prejudice that will remain ingrained in the minds of many staff. For her part, Mrs.
Echaquan’s stretcher neighbour said she had a front row seat to the lack of humanity of some of
the attendants and nurses, telling us that she heard one of them say to her colleagues, “She
threw herself to the ground, you know. According to this witness, Mrs. Echaquan screamed that
she was afraid of dying. A nurse reportedly said: “Stop shouting, you’re disturbing everyone
here. We’re not in a daycare centre here, we don’t manage babies. For this witness, the care is
simply devoid of empathy and she doesn’t understand why the nurses make fun of Mrs.
Echaquan. During the hearings, this testimony provided a clear picture of how care can be
provided with a double standard depending on where a patient comes from and with the label
they are characterized with.
At around 10:16 a.m., Mrs. Echaquan was still shouting, but she was not struggling and was
somewhat calmer. The doctor in charge of consultations and hospitalisations in family medicine
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then stated that she had been alerted on her mobile phone. She understood that the patient’s
screams were due to agitation and not to any pain.
However, without having seen Mrs. Echaquan, she then prescribed chemical restraint with 5 mg
of Haldol® and, if necessary, physical restraint with close monitoring. A witness told us that the
doctor had initially prescribed a dose of 3 mg, but then changed her mind and told the CPNP:
“We’ll give her 5 mg to calm her down as much as she needs. Although the dose is not strictly
inappropriate, since it is the same dose suggested in the manufacturer’s monograph, what we
believe to be true is that it is at least questionable. The doctor, by not taking the opportunity to
see the patient in crisis in person, also missed a great opportunity to better understand what
was causing her patient’s erratic behaviour. Instead, she endorsed the judgement of her
colleagues and supported a diagnosis of withdrawal that was not supported by any evidence.
Then came the time for the Haldol® injection, at around 10:20. Mrs. Echaquan is calm and even
exposes her buttocks to receive the injection. Just before the transfer, Mrs. Echaquan’s attitude
varied, according to the witnesses. She seems absent. In turn, she is seen repeatedly banging
her occiput against the wall, then cradling herself on the stretcher with her legs crossed. She
asks for her mobile phone. She no longer screams, but is obviously agitated, possibly suffering.
According to the staff heard during the hearings, this behaviour is worrisome, even frightening to
the other patients in the vicinity. Shortly after 10:25 a.m., it was therefore decided to transfer her
to alcove 10 and isolate her. At about the same time, Mrs. Echaquan’s cousin, who was also
under observation in the emergency room reported hearing Mrs. Echaquan say her partner’s
name and calling for help.
At around 10:27a.m. after her transfer, Mrs. Echaquan posted her video live on Facebook. The
comments speak for themselves. The translation was provided by the Sûreté du Québec:
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“Ni cta ni akohikon: It hurts me
Carol pe ntamici : Carol, come see me
Ni taci sa micta mackikikatakoiin: They are overdosing me with drugs
Wipatc tca: Make it quick […]
3 min 59 s: We’ll leave it on the ground for a while, eh.
4 min 21 s: We’ll look after you. I think you’re having a hard time taking care of yourself
right now. But we’ll do it for you, OK?
Asti of a thick tabarnouche.
This is better off dead […].
5 min 25 s: Patient starts moaning loudly.
Are you done messing around! Are you done with that… piss off.
Joyce: If you were in my shoes right now.
Hey, you’re thick in the head
Joyce: I don’t like it when people tell me I’m being silly about it.
Well, you made some bad choices, baby
What would your children think, seeing you like this?
Joyce: That’s why I came yesterday.
Well, it’s better for stuffing than other things… eh
Especially since it’s us who pay for it…
6 min 9 s : Joyce moans loudly.
His damn cell phone is there. ”
When the nurse realises that the conversations between her and her colleague are being
recorded, she grabs the mobile phone and hurries to erase the recording, which is not possible
because it has already been broadcast. As for the beneficiary attendant, according to her, her
comments should only be seen as benevolent. During her testimony, she defended herself by
saying that she had been taught to provoke patients to make them react. In fact, according to
her, these were not condescending or reductive remarks, but rather a way to make Mrs.
Echaquan feel proud so that she could take charge of her life.
Both would deny having any racial prejudice, one responding that she would have reacted the
same way to “a woman on welfare with lots of children”. We did hear the apology that the nurse
and the orderly made to the family during the investigation. The treatment of Mrs. Echaquan is
nonetheless unacceptable. Moreover, the fact that neither of these individuals admitted to
having a racist bias raises doubts about whether their introspection was sufficient. The very fact
that they did not admit to having a bias is even more distressing, as it illustrates this lack of
compassion for a human being.
In the meantime, another beneficiary attendant, who had been made aware of the video,
immediately notified the manager that Mrs. Echaquan had filmed employees. The manager then
inquired about the situation, but did not fully appreciate it until late in the evening when she was
sent the second video, which was recorded by Mrs. Echaquan’s daughter. Yet she had also told
the nurse earlier in the day not to worry, even though she had seen the video taken by Mrs.
Echaquan. The social worker had also informed her of a call from the clinic referring to insults to
Mrs. Echaquan, including calling her “thick”. She did not seek to investigate the situation with
the seriousness required when the events were related to her. When asked about alleged
derogatory remarks by staff, the head of the department said that this certainly existed, but that
she had not witnessed it. However, a nurse reported that she had informed the head of
department in the past that derogatory remarks had been made to a Syrian family who needed
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an interpreter, expressing the desire “not to waste too much time with them, [as] they are not
from here”. No sanctions or investigations were carried out as a result of this denunciation.
In the case of Mrs. Echaquan, had it not been for the video footage, it is likely that this event
would never have come to public attention. When the system withdraws defensively into itself,
that is the very definition of systemic racism. Systemic racism is insidious. The Commission des
droits de la personne et de la jeunesse (CDPDJ) defines 1it “as the sum total of disproportionate
exclusionary effects that result from the combined effect of prejudiced and stereotypical
attitudes, often unconscious, and policies and practices that are generally adopted without
regard to the characteristics of members of groups prohibited from discrimination. ” Although
sometimes unintentional, this form of racism has the effect of perpetuating the inequalities
experienced by people of indigenous origin. Unfortunately, Mrs. Echaquan is not alone in her
experience. Members of the community, including Mrs. Echaquan’s brother, have expressed
similar fears because of past experiences that were similar. When Mrs. Echaquan’s daughter
arrives, she films her mother. Mrs. Echaquan is in a five-point restraint. To her eyes, she looks
dead. Her testimony is heartbreaking, she tells us: “I will regret all my life that I did not untie
her”. The video recording allows us to see that Mrs. Echaquan’s respiratory amplitude is not
perceptible. About a minute into the video, CPNP is seen going to Mrs. Echaquan’s bedside.
The CPNP tries to get a response from Mrs. Echaquan by calling out to her and gently shaking
her shoulder. She takes the vital signs and obviously does not get the expected values, as she
tells Mrs. Echaquan’s daughter that she needs to make a call to transfer her to the resuscitation
room. The CPNP returns two minutes later and takes the vital signs. The CPNP explained,
without appearing very convincing, that Mrs. Echaquan’s lack of response was due to the
medication. In fact, and the expert also concurs, Mrs. Echaquan was in an advanced coma at
the time, which required immediate and vigorous treatment.
At a
