2021 death of Innu man found frozen in a portable toilet in Montreal was avoidable, coroner finds

The death of Raphaël ‘Napa’ André, who was found dead in a portable toilet in downtown Montreal on Jan. 17, 2021, was avoidable, according to a Quebec coroner.

Coroner Stéphanie Gamache released the findings of her public inquiry on Thursday.

She made 23 recommendations aimed at preventing deaths in similar circumstances.

“His death was avoidable because the cause of his death was hyperthermia. Yes, he was severely intoxicated, but it was hyperthermia. Had he been in a secure place that evening, he would not have passed away,” said the coroner.

She was emotional presenting the findings of her 75-page report.

“Just the circumstances, the circumstances of the passing,” she said with tears in her eyes, when asked why the presentation brought up emotional moments for her.

The man of Innu descent was experiencing homelessness. He was known as Napa Raphael in his community, and was given this name during Gamache’s inquest.

According to testimony heard at the public hearings, last spring, the day before his death, Napa Raphael was unable to enter the Open Door shelter where he had gone because it was experiencing a COVID-19 outbreak at the time the public health emergency was declared.

John Tessier worked at the Open Door Shelter at the time of André’s death and says public health told them to close at 9 p.m., instead of being open 24/7 as usual.

“It just didn’t make any sense, and we knew that there were going to be poor consequences for it, and sure enough, you know, something tragic happened,” said Tessier on Thursday.

Tessier said, years later, the story weighs heavy on him. The former coordinator at the shelter says that night, Andre had to be woken up — and was the last person to leave the shelter.

“I’m probably one of the last workers to have contact with him. I had to ask him to leave,” Tessier said. “He adamantly did not want to. He had nowhere to go, of course, and you know, when you need to put somebody out and you don’t see them the next day, something horrible happens, it has an effect on people, and the people that make those decisions from Zoom, they don’t anticipate that.”

Chief Réal Mckenzie of Matimekush-Lac-John First Nation — André’s northern Quebec community — was present in audience at the inquiry and delivered remarks after the presentation, stopping to give Gamache a hug at one point. He said it was “unacceptable” that André had died because he didn’t have access to shelter.

“I request a really change on that part. You knock at the door one minute before the close, you have an answer like, ‘No room,’ come on, forget the rules, and ‘Come in, my son, come in, my friend.’ That’s a human being,” he said. “It’s [a] human question.”

In the report, which comes after 13 days of testimony from 51 witnesses in last year’s public inquiry, Gamache highlighted, among other things, the urgency of ensuring better communication within the health network to ensure centralized care, the need to improve coordination between the different actors involved in the fight against homelessness, the need to set up accommodation resources adapted to the realities of Indigenous people experiencing homelessness and the importance of eliminating the seasonal nature of emergency accommodation resources.

“We must keep in mind our collective responsibility when a death occurs that was avoidable,” she wrote in her report’s conclusion.

André was heavily intoxicated with alcohol at the time of his death, but according to the autopsy, he died of hypothermia.

“If a door had been opened for 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 because of alcohol,” Gamache wrote.

The coroner identified five themes to solidify a safety net for homeless people:

• The importance of providing centralized monitoring for the itinerant population that consults in different institutions of the health network;
• The need to develop places that make it possible to welcome customers in a state of intoxication and with a problem of acquired brain injury;
• The importance of cultural security at the heart of initiatives to help homeless people;
• The importance of taking into account the special needs of vulnerable and homeless people when making decisions in an emergency context and more particularly in the context of a health emergency;
• The need to provide permanent funding for resources that provide emergency housing.

23 recommendations made

The 23 recommendations mainly address the provincial government and its ministries and are structured around the five safety net themes.

Gamache recommends that the Ministry of Health and Social Services and Santé Québec should deploy resources dedicated to people in a situation of homelessness or at risk of becoming homeless.

She also recommends that they improve the support adapted to their reality offered in the institutions of the health network that are in contact with homeless Indigenous people. It is also important, according to the coroner, to integrate Indigenous healing practices into these institutions.

It also asks Quebec to quickly initiate steps so that emergency accommodation services are continuous and permanent.

Santé Québec was recommended to train stakeholders in community organizations that offer emergency accommodation on the recognition of signs that affect people’s ability to maintain their safety in contexts of intoxication.

Gamache also asks to ensure the deployment of the Digital Health Record in order to facilitate inter-institutional communication for centralized user care.

The coroner also recommends that the mobile team in mediation and social intervention of the City of Montreal have funding to ensure its sustainability in order to ensure adequate interventions.

The purpose of Gamache’s public inquiry was to shed light on the events that led to Napa Raphael’s death and to make recommendations to prevent this type of tragedy from occurring again.

During the public hearings, Gamache made it clear that this was not a public inquiry into homelessness in the broadest sense.

“We must learn from the death of Mr. André so that he is not in vain,” Gamache wrote in her conclusions. Tessier said he agrees with the statement.

“I did read in the report that she said she hopes that this tragedy isn’t wasted, that something good comes out of it, and I’m sure André would want that,” he said. “That’s what I hope, that there is some actual change. Not just words on a report or a paper.”

“Some reports, they stay on the table. Nobody moves,” said McKenzie. “That’s my message to the government: We should take that seriously and move on [it,] because it’s a concern about life. Not money, not economy, not mining people, but the life of these people.”

–With files from The Canadian Press