The death of an Inuit man who spent 11 hours on the floor of his cell at Bordeaux prison in 2020 could have been avoided had guards been concerned about his health, a coroner’s report says.
Sick and confused on admission, Bobby Kenuajuak, 44, was found dead less than 24 hours after arriving at the Montreal Detention Center.
“[Il] should have been evaluated in the infirmary. In my opinion, this assessment could have prevented his death,” says coroner Karine Spénard in a report consulted by the journal and first made available to indigenous broadcaster APTN.
She concludes that the inmate likely died of a malignant cardiac arrhythmia related to alcohol withdrawal.
“It was truly heartbreaking to learn the details of the investigation. [Les gardes] left him in the same position for hours without checking his health,” testified his sister Annie Hickey Kenuajuak.
She remembers a simple and basically nice man who was known in his youth for his talents as a hockey player and accordion player.
At the age of 23, Bobby Kenuajuak also shot an internationally acclaimed documentary about his home village of Puvirnituq on behalf of the National Film Board (ONF) and worked as a cameraman for several years.
Photo provided by Annie Hickey Kenuajuak
Lying on the floor
After developing an alcohol addiction and living on the streets, Mr. Kenuajuak ended up in prison on July 10, 2020 for “aggressive and disorganized” behavior.
During the night, an agent notices that the father is lying on the ground, but attributes his position to the current heat wave.
It wasn’t until the next morning, after the shift change, that a guard knocked on his door with no response. His death was declared shortly thereafter.
Coroner Spénard accuses the officers of not having checked the health of the inmate given his many symptoms.
“[Leur] role [est] making sure people in detention are alive and in good health,” she recalls.
Missed Opportunities
“There were several rounds, they had several opportunities to inform the infirmary that he was not well. All it took was a phone call,” said prison attorney Alexandra Paquette, who complained about prejudice against First Nations inmates.
She points out that the floors in Bordeaux are extremely dirty – sometimes due to excrement – and that rodents and cockroaches are plentiful.
The coroner’s report indicates that the Ministry of Public Security has already recommended that the facility remind its employees of their monitoring duties and take action regarding the officer on duty on the night of July 11, 2020.
“I wonder who these people are and why they work there if they don’t care about others. I would have liked [Bobby] be treated with respect and dignity. Like a human,” Annie Hickey Kenuajuak concludes sadly.
A few weeks ago, Quebec’s chief medical examiner ordered a public inquiry into the death of Nicous D’Andre Spring, who was arrested in Bordeaux last December.
Photo archive, Ben Pelosse
Excerpts from the report of coroner Karine Spénard
“I find it surprising that no attempt was made to communicate with Mr. Kenuajuak given his excitement upon arrival at the accommodation area and his absent-mindedness afterwards.”
“Viewing surveillance cameras […] confirmed that Mr. Kenuajuak walked with difficulty as if drunk and that he crouched several times.”
“The department chief said he had no details of Mr. Kenuajuak’s unsteady gait and therefore did not contact the infirmary as there was no indication of a medical emergency when he was notified.”
an agent”[trouve] Mr. Kenuajuak was lying on the ground at around 11:50 p.m., curled up on his left side and making his way to his cell door. She says she immediately wondered about the reason for this position […] but that the situation is not uncommon as prisoners often sleep on the floor during hot spells.
“A period of approximately eleven (11) hours elapsed during which Mr. Kenuajuak remained in the same position without a health check being made.”
“The officer further pointed out that correctional officers can only perform one mass at night and therefore it is impossible to know how a detainee is doing without making gestures that could wake him up. . These comments are worrying.”
“Both the correctional officers on duty as of July 10, 2020, and the department chief could have verbally informed the infirmary staff of Mr. Kenuajuak’s condition.”
Do you have any information about this story that you would like to share with us?
Do you have a scoop that might be of interest to our readers?