Quebec coroner offers slew of recommendations after deaths of Ullivik guests in 2022
Mary-Jane Tulugak and Nellie Niviaxie died within 24 hours of each other after they were hit by vehicles
Coroners reports into the deaths of Mary-Jane Tulugak and Nellie Niviaxie in 2022 were released earlier this month. The pair died within 24 hours of each other, in similar circumstances, while staying at Ullivik medical boarding home near Montreal, although the incidents were not related. (Photo by Cedric Gallant)
Coroner’s reports into the deaths of two Nunavik women during their stays at a medical boarding facility near Montreal two years ago include several recommendations to improve the safety of Inuit in the city.
Mary-Jane Tulugak, 22, died on Aug. 19, 2022, after she was struck by a vehicle on Hwy. 520. Nellie Niviaxie, 26, died less than 24 hours later after she was struck by multiple vehicles on Hwy. 20.
They were both staying at the Ullivik medical lodging facility in Dorval, Que., which houses Nunavimmiut who travel south for medical treatment.
Coroner Éric Lépine announced an investigation into the deaths about a week later. Those investigation reports were released earlier this month and include information about Tulugak’s and Niviaxie’s deaths as well as 12 recommendations aimed at preventing similar incidents.
According to the reports, both women spent the evening at Café-Bar Dorval, about a 25-minute walk away from the centre. The incidents were not related, but the recommendations are the same for both deaths.
On Aug. 19, Tulugak returned from the bar with the help of police around 3 a.m. and she was left in the care of a security guard because the Ullivik’s manager in charge of the facility at the time was on a break.
The security guard did not let Tulugak into her room but instead left her to roam around the common area for 30 minutes until she left and called a taxi. Tulugak was hit by a vehicle at 4:12 a.m. and later died.
Ullivik’s manager was not informed until 3:57 a.m. that Tulugak had returned and subsequently left.
In the early morning of Aug. 20, Niviaxie was at the same bar and left alone at 12:26 a.m. She was spotted 30 minutes later walking on the side of a nearby highway. She was initially hit by one vehicle, then multiple other vehicles while lying on the road unconscious. At 1:15 a.m., police said she had died.
The coroner made recommendations for Ullivik centre; Inuulitsivik Health Centre, which provides health services to Nunavimmiut in Montreal; the bar where both women had been before their deaths; Nunavik’s Ungava Inuulitsivik Health Center and Tulattavik Health Center; Montreal police; Makkivik Corp.; Native Friendship Centre; City of Dorval; and McGill University Health Centre.
The recommendations include making sure a manager is available at Ullivik at all times and that the centre review all interventions by security staff; that Café-Bar Dorval continue to train staff in preventing alcohol overconsumption; that Nunavik health officials provide better preparation for patients before they head south; and that southern health providers make sure somebody is there to help Nunavik patients who are struggling, among others.
Café-Bar Dorval is owned by Placement Sergakis Inc., a company that manages bars, restaurants and real estate across Montreal.
“We feel very sad and very sorry that this happened,” CEO Peter Sergakis said in a phone interview.
The coroner recommended Café-Bar Dorval management meet with Ullivik management to come up with ways to prevent alcohol overconsumption.
Sergakis said this has happened, and the two have established a direct line of communication when someone from Ullivik requires a ride from the bar.
“We are going to work together in the future to find solutions,” he said, adding his company has strict rules against over-service of alcohol
As for the recommendations for Ullivik, assistant director Yves Lorion said in an email statement that “several measures already in place have been reviewed, improved or implemented since the tragic events.”
Lorion said the recommendations align with what the medical boarding home is already doing.
“We encourage our Nunavimmiut clients who may be unfamiliar with the realities of the south to seek assistance from our staff,” he said.
Ungava Tulattavik Health Center responded as well to the recommendation to offer information for patients before their departure to Montreal.
Spokesperson Nathalie Poirier said in a French email that there is a liaison service in place that takes care of clients going south for treatment. The process includes the chance for patients to ask questions and have them answered in whatever language they prefer.
According to Lorion, the City of Dorval implemented supportive measures such as Inuktitut signage, better road safety and cultural workshops for local police.
if the patients were allowed into their rooms, this would not have happened. The curfew at Ullivik needs to be removed or changed.
Curfew exists so that people get a proper rest. They’re staying at Ullivik so they can get medical treatment. They are not going to Ullivik because it’s a free trip south, so learn to live with the rules. If you can’t follow them, then people should start paying their own tickets or being fined. I’m sorry but enough is enough, stop with the damn entitlement and realize that there are rules and consequences for breaking them.
If the curfews and policies are not in place, the “home’ would be in chaos. have you ever witness ppl from the north going wild when they not have been to the city in long while. madhouse….many patience DO NOT obey….
The patients (not all but some) are the irresponsible people who leave the north to go to their hospital appointments or surgeries in the Montreal area. Before entering the Ullivik and getting a room key the Inuk has to sign a waiver indicating that they will follow the rules and regulations while their stay at Ullivik. One of the agreements signed is not to get drunk and return to Ullivik. No intoxicated people are permitted into their rooms because they could make a disturbance to other patients or escorts staying at Ullivik. I just wish that each community nursing station will meet with each Inuk before their scheduled departure from their nunavik community and explain to the patient or escort that “if you do get heavily intoxicated, you will be responsible to pay for your own hotel room and you will be responsible for purchasing your own airfare ticket (AIR INUIT/CANADIAN NORTH) home town. We have to stop pampering the adult Inuit who (are abusing) has to travel to Montreal for their hospital appointments or surgeries and allow them to make a disturbance at Ullivik where people are dying of cancers, and other illnesses. Stop blaming Ullivik workers, their security team, their office workers, the police and their home town community liaison nurse. The young teenage 18 year olds to grown adults (men / women / they) have to take responsibilities for their actions and choices. Don’t blame other people. Don’t be hypocrites’. Don’t be Racists when telling the security staff and front desk workers that they are just there to steal the Inuit monies because they are not permitted to enter Ullivik while intoxicated. It saddens me that Inuit of Nunavik were run over and killed like dogs but most Inuit who travel to Montreal and stay at Ullivik are grown men and women who believe they are entitled to do what they want to do and when they want to do it. You are all grown men and women. Stay away from the poison of alcohol or drink in moderation. Once again, they do not want to listen to the white or black man because there are rules and regulations that the Inuit has to follow. Stop playing the poor me. Its old. Its time to live in 2024 instead of living in the 1960’s and 1970’s, mentality.
1person makes mistake, blame all nunavik? Booooooo
They do keep statistics….. I’ve read them in this paper. It’s public knowledge.
I miss you baby girl. Your children are growing up just fine. I get stressed out sometimes, but I will never give up.
Where can we find the report made by the coroner with the recommendations
My sincere condolences to the 2 Inuit women family members and loved ones who died from a horrific death while their stay at Ullivik either as a patient or an escort. But wasn’t their 4 Inuit people (3 women and 1 man) who was struck by vehicles?
Wasn’t there a young Inuk man who was walking at or near the highway when he was killed by a vehicle? Or, wasn’t there another Inuk woman who was run over at or near the Ullivik Transit? I believe it was at or near a transportation company just minutes away from Ullivik?
Recommendation for everyone else to change and adapt to peoples personal choices.
There are sad events and there is a lot more than they were just intoxicated but at what point do we stop holding hands.