Although her death has been ruled accidental, the report says "the racism and prejudice Echaquan faced was certainly a contributing factor in her death" and "her death could have been prevented." The coroner who wrote the report, Gehane Kamel, also recommended that the Quebec government "acknowledge the existence of systemic racism and "make a commitment to help eliminate it."
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"Efforts are all the more necessary because the findings of this inquiry indicate that Ms. Echaquan was indeed ostracized, that her death was directly related to the care she received during her hospitalization in September 2020," the coroner's report reads.
According to the report, the autopsy revealed that Echaquan died of pulmonary edema, a buildup of fluid in the lungs. The report also outlines how Echaquan's "clinical situation" could have been reversed.
Besides calling on the Quebec government to acknowledge the existence of systemic racism, the coroner made several recommendations for the CISSS de Lanaudière, the Order of Nurses of Quebec and the Ministry of Higher Education, which is responsible for the educational institutions that train physicians, nurses and nursing assistants.
These recommendations include better integrating the hospital's Manawan liaison officer and updating the training curriculum to cover Indigenous patient care, taking into consideration "the realities of Indigenous communities."
The report recommended that Quebec acknowledge systemic racism. It also said racism and prejudice played a role in Echaquan's death.
"The only place where I don't agree is when we say that there's a 'system' because for me a 'system' is coming from upstairs, coming from the top people, and I don't see this in the health care network, for example," Legault said at a press conference on Tuesday, following the release of the coroner's report.
"What happened to Mrs. Echaquan is terrible [...] and few employees, not only one, didn't deliver the right services to her."
He reiterated that people who believe in systemic racism in Quebec don't have the same definition that he does.
"We don't have a system [of racism], top to bottom, and it's a question of fact," he said.
He emphasized the need to "stop dividing Quebecers" with arguments about systemic racism.
"Even [the coroner who wrote the report] Mrs. Kahmel, she's saying that we have not to put all the emphasis only on words. We have to put emphasis on actions to change the situation and, on that, I fully agree," said Legault.
"I'm not sure what it's like to see your daughter, your sister, your mother, your friend, your lover disappear from one day to the next without a trace. And on top of that, to have the impression that your government doesn't really care, or at least not enough. No one should have to go through that in Quebec," Legault continued.
"I'm convinced that the vast majority of Quebecers are ready to fight racism."
"As such, we want to encourage everyone to approach September 30 as a day of action. Reflection is not enough - participating, listening and supporting Indigenous people, who are still reeling from the multi-generational trauma of residential school, is a proactive stance to commemorate this day."
Many people at the march wore orange shirts, a symbol of truth and reconciliation. Orange Shirt Day, a grassroots movement that commemorated residential schools and honoured their survivors, was the precursor to the National Day for Truth and Reconciliation, and some people still refer to it by its original name.
"Joyce Echaquan lost her life because somebody thought she didn't matter," said Ellen Gabriel, a Mohawk activist and artist from Kanehsatà:ke Nation, addressing the crowd. "Don't make this the last demonstration you come to. Don't make this the last thing you do for those children who never came home."
While being pursued by journalists on his way out of the National Assembly on Thursday, Quebec Premier François Legault gave a short answer as to why September 30, the National Day for Truth and Reconciliation, isn't a statutory holiday in the province.
"We need more productivity," the premier said in response to a journalist's question.
C'est la journée dédiée aux enfants disparus dans les pensionnats, aux survivants et à leurs descendants.
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