Vadeboncoeur checked Echaquan’s medical background, autopsy report and hospital records, and made recommendations to the coroner Géhane Kamel.

He said the 37-year-old mother is a 7-year-old mother with serious health problems, including severe cardiomyopathy, which has been treated since 2014.

Vadeboncoeur stated that after giving Echaquan a strong sedative, Echaquan was not properly supervised on the morning of September 28, 2020 (the day of the live broadcast). Later that day she went into cardiac arrest and died.

After her Facebook video showed hospital staff verbally abusing her, her case made international headlines. The coroner’s inquiry is investigating her death and how the health care system treated the indigenous people.

Vadeboncoeur said that he was troubled by another videotape, which was taken by Echaquan’s daughter that morning, and that the videotape started at 11:39 in the morning.

He said that the unreleased video showed that Echaquan barely breathed, his face was pale, and he might even be in a coma.

Vadeboncoeur said that he did not understand why a resident gastroenterologist took her vital signs at 11:35 am according to records, calling her “sedated”.

He said: “There is a difference between being calm and being in a coma.”

Patrick Martin-Ménard, a lawyer representing Echaquan’s family, asked Vadebocoeur whether it would make a difference if he was monitored more closely.

With proper monitoring, Vadeboncoeur said the answer may be yes.

Inexperienced staff

The nursing candidate in the emergency room that day had only a few months of experience and had not yet obtained her nursing permit. The testimony revealed this week that she had 9 patients under her care that morning, including several patients in poor condition.

The head nurse of the hospital, Josée Roch, said on Thursday that after the policy change, college-educated nursing candidates will not be allowed to work in the emergency room until the end of 2019.

Vadeboncoeur said that experienced employees will immediately realize that Echaquan is in poor condition.

He said he hopes that this investigation will solve the long-standing shortage of personnel in the Quebec medical system.

He said: “This needs to be resolved because it will affect real life and patients, and there is some understanding of this.”

Rare heart conditions

The pathologist who performed the autopsy also testified against Echaquan’s heart today.

Dr. Richard Fraser of McGill University Health Center said that Echaquan suffers from a very rare disease, rheumatic heart disease, sometimes caused by streptococcal pharyngitis. Caused by early infection

He said this was the first time he saw it in 3,500 autopsies.

Fraser said he did not find any acute heart problems that could explain why Echaquan entered cardiac arrest.

Chemists and forensic toxicologists who testified earlier in the day said that Echaquan may have been “powered by drugs” in general, but was not as addicted to opioids as some health care workers suggested in the investigation.

The coroner’s inquiry also heard more about the attitude of the Lanaudière staff in the reception area of ??the Joliette Center.

According to the nurse who provided the nurses, out of its 200 employees, only five signed the Atticamek cultural training program offered in 2018.

Alexandre Deslauriers St-Jean, a nurse from Manawan who is completing his master’s degree, said that he wanted to solve the communication failure between Joliette Hospital and Manawan’s health clinic.

Employees are paid to participate in training.