A coroner says a Montreal-area Inuit health centre should review its security measures in light of the deaths of two patients who were struck and killed on highways within a 24-hour span in 2022.
Coroner Éric Lépine examined the death of one of the two women — Mary-Jane Tulugak, 22 — and issued a series of recommendations in his report released Thursday.
Tulugak and Nellie Niviaxie, 26, had travelled to Montreal for medical treatment and had been staying at the Ullivik health centre in Dorval, Que., which is overseen by the health board in Nunavik, the northern Quebec territory where the two women lived.
Tulugak was in a wheelchair after surgery, and on Aug. 19, 2022, was barred entry to Ullivik’s living quarters by security because she returned to the centre from a nearby bar and was drunk.
Lépine says the health centre’s protocols stated that a supervisor should have been informed about Tulugak’s attempted entry, but the coroner says that person was on a break and wasn’t informed until after the patient had left.
Tulugak was struck and killed about 380 metres away on Highway 520, and Niviaxie died less than 24 hours later after she was hit on nearby Highway 20.
Lépine says many of his recommendations have already been implemented by the Ullivik health centre.
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