When she arrived at the Ullivik Center in Dorval on the night of August 19, 2022, Marie-Jane Tulukac was heavily intoxicated. A living unit manager should visit her immediately and provide “assistance appropriate to her condition.” But after a 30-minute wait, the young mother of three rolled out of her wheelchair and was fatally injured on Highway 520 a short time later.
“The circumstances of these deaths are troubling and raise questions, many of which remain unanswered,” we read in Coroner Eric Lepine’s report dated June 18.
A resident of Buvirniduk village on the coast of Hudson Bayme Duluk worked at the municipality but was on maternity leave. After injuring his ankle, he was flown to Montreal on July 28, 2022 for surgery.
M waiting for his surgeryme Lived in the center of Tulukkak University. It was her first stay. Up to 140 patients from the north who pass through Montreal can receive specialized care at the Ullivik Center, located not far from the airport in Dorval. Because even though basic care is provided in Gujjuak and Buvirniduk, every year many patients have to travel to the metropolis for treatment.
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Mary-Jane Dulucak
No room
M operationme Tulukkak has been postponed twice and will be played only on August 18. That same evening, when she returned to the center of Ulivik, the young woman went to Café-Bar Dorval, not far away. She stayed there until closing at 3am. Police officers found her a short time later, on the ground not far from the bar, and took her back to the Ulliwick Centre. His blood alcohol level was 222 mg/dL, the coroner said. A concentration “certainly weakened his physical and psychological faculties,” he writes.
According to the internal directives of the Utlivik Center, intoxicated persons are not allowed in the rooms. On August 19, 2022, security officials Mme Tulukak that she could not ride. However, Ullivik’s central reception has two rooms, and intoxicated residents cannot reach the upper floors. A life unit manager usually needs to evaluate these cases.
But on the evening of the tragedy, the manager on duty was on break and was never informed of M’s presenceme Duluk. “As per the rules in force, Mme Dulugak should have recommended to the Head of the Life Unit who could provide appropriate assistance for his health condition,” it read.
Conversely, for 30 minutes, Mme Dulucak moved to the ground floor of the Invigil Center “without any specific intervention by security agents”. The young mother left the scene around 4am.
Five minutes later, the Ministry of Transport’s surveillance cameras captured Mme Dulukak, in her wheelchair, enters Highway 520 via Exit 2. She was driving against traffic. She wanders the tracks for some time before she is hit by a car taking Exit 2.
Twelve Recommendations
In the report, Mme Tulkuk showed no signs of psychological distress. She was “eager to return to her community and see her children again.” Various measures were taken following the death of Mr.me Duluk. Notably 24 hours later, another woman, Nellie Niviaxie, a resident of Ullivik Center, lost her life in similar circumstances.
In particular, a fence was erected to block access to Highway 520 near the center of Ullivik. A safe path has also been established for Inviwick residents to walk to nearby businesses.
Coroner Lepin makes 12 more recommendations. He asserts that “the specialized health services provided to the Inuit of Nunavik sometimes involve long stays in Montreal in a vulnerable environment due to their medical conditions and distance from their own communities.” According to the coroner, in this context one should avoid evaluating patient safety solely from the angle of personal responsibility.
Me Lépine recommends that the Ulivik center have a live-in unit manager at all times and that security agents be given precise instructions. He also requests that the post of social worker at the Ulivik Center, which was canceled for budgetary reasons, be reinstated.
The Inuulitsivik Health Center must also ensure that first-time visitors to the Ullivik center are given “minimum information about safety issues surrounding their stay in the municipality.”
Coroner Kafe also speaks to Dorval. “Several police interventions by the SPVM have taken place in the parking lot near this establishment in recent years, most of which involved intoxicated individuals,” the statement read. “Continuously reminding staff of the rules that apply to alcohol license holders, especially the rules that prohibit serving alcohol to an intoxicated person,” believes Me Lépine.
McGill University Health Center “must integrate the patient’s residency into its assessments of clinical care priorities.” […] To avoid long stay in the metropolis.
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