MONTREAL — It was a case that shook Canada: A 37-year-old Indigenous mother of seven died in a Quebec hospital last year after a nurse had taunted her, “You’re stupid as hell,” only good at having sex, and “better off dead.”
On Tuesday, a coroner said that the death of the woman, Joyce Echaquan, could have been prevented and that racism and prejudice had played a role in her treatment. Because of bias, she said, medical staff had erroneously assumed Ms. Echaquan was suffering withdrawal from narcotics.
The coroner, Géhane Kamel, also called on the Quebec government to recognize “systemic racism” in the health care system and across the province.
Ms. Kamel had released a report last week that examined the medical circumstances of Ms. Echaquan’s death and had detailed a series of lapses in her care. The evidence suggested that Ms. Echaquan had died of a pulmonary edema, an excess of fluid in the lungs, the report found.
If Ms. Echaquan were a white woman, she would still be alive today, Ms. Kamel said at a news conference on Tuesday explaining her findings. “This was a death that could’ve been prevented,” she told reporters.
The evidence, she added, did not show that Ms Echaquan was experiencing withdrawal from narcotics use.
Ms. Echaquan, who suffered from heart problems, died on Sept. 28, 2020, after capturing the medical staff’s taunts in a Facebook Live broadcast that went viral across Canada, spurring widespread anger. The video became a potent global symbol that Canada’s vaunted health care system was failing Indigenous people.
The retired Quebec Superior Court Justice Jacques Viens had already concluded in a 2019 report that “cultural barriers” and prejudice in the health care system in Quebec were having “dire consequences” for Indigenous people. He detailed numerous problems, including “delayed diagnoses” and the failure of medical staff to order necessary exams or medication.
Following the broadcast of Ms. Echaquan’s video, the hospital fired the nurse and an orderly. But the government of Quebec’s premier François Legault has not acknowledged that systemic racism exists in the province.
It has also refused to adopt “Joyce’s Principle,” a set of policies aimed at providing fair access to health services for Indigenous people, because the document outlining the policies refers to “systemic racism.”
From the moment Ms. Echaquan arrived at Joliette Hospital in Quebec, medical staff assumed she was suffering from a drug withdrawal and treated her with contempt, Ms. Kamel said.
Ms. Echaquan was “infantilized and labeled as a drug abuser,” she told reporters, and the care she received was “tainted with bias.”
“Some were silent witnesses. Some just did not act,” Ms. Kamel said. She added: “In this case we have proof that the system failed.”
In her report, Ms. Kamel called on the Quebec government to recognize systemic racism and take steps to eliminate it.
“We have witnessed an unacceptable death and we must ensure that it was not in vain and that we learn from this tragedy as a society,” she wrote in her report. “It is therefore unacceptable that broad swaths of society deny a reality that is so well documented.”