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Andr茅, 51, was found steps away from the Open Door shelter in downtown Montreal, which had been closed by public health officials for overnight stays because of plumbing problems and a COVID-19 outbreak. Quebec had also imposed a nighttime curfew to curb the spread of the virus.

鈥淲e must keep in mind our collective responsibility when a death occurs that was avoidable,鈥� coroner St茅phanie Gamache wrote in her report.

Andr茅's death was attributed to hypothermia in the context of severe alcohol intoxication. His blood-alcohol level was more than four times the legal limit for driving a vehicle. Nonetheless, Gamache said, he could have been saved.

"It's impossible for me to conclude that Mr. Andr茅 was the only person responsible for his fate," Gamache wrote.聽

During a news conference later in the day, she said, "Yes, he was severely intoxicated, but it was hypothermia, and had he been in a secure place that evening, he would not have passed away."

Her 75-page report includes 23 recommendations, such as better communication between actors in the health network and culturally sensitive accommodations for Indigenous Peoples. She said all of the recommendations are intertwined.

"The problem of homelessness is complex and this public inquiry cannot, unfortunately, provide all the answers," Gamache wrote. However, we are fortunate to live in a society that is making efforts to reduce social inequalities."

The inquiry found that Andr茅 spent a lot of time in the health network, notably in emergency rooms. He'd often talked about entering a program to curb his drinking. His health records numbered more than 4,000 pages, the coroner noted.

Gamache became emotional as she discussed Andr茅's case. "It was a difficult investigation because the circumstances of the death were, in my opinion, truly inhumane," she said, choking back tears.

Fifty-one witnesses testified in May and June 2024. Among the most telling moments was when his mother, Suzanne Chemaganish, a local Innu elder, came to testify.

"I think her disbelief in not understanding that in this big city, all the doors were closed to her son," Gamache said.

After taking in the report, R茅al McKenzie, chief of the Innu Nation of Matimekush-Lac John, told reporters that Gamache's report was well-received and that he would explain it in Innu during an address to the community, located near the border with Labrador.

McKenzie echoed some of the disbelief that had been expressed by Andr茅's mother. In a community that often deals with extreme cold, the idea of turning someone away makes little sense.

"I request a real change on that part," McKenzie said. "If you show up at the door one minute before close, you get an answer like 'no room'? Come on, forget the rules and (say) 'come in my son, come in my friend,' that's a human being, that's what we should do."

Social Services Minister Lionel Carmant said the Quebec government has already implemented several of the recommendations in Gamache's report, including the one calling for culturally adapted services to First Nations and Inuit dealing with homelessness. He said part of the money set aside for homelessness measures is destined for Indigenous Peoples.聽

鈥淲hat happened to Rapha毛l Andr茅 in 2021 shook us all. It is incredibly sad. We acknowledge the recommendations made by the coroner," Carmant said in a statement.

Gamache's report also recommends turning seasonal emergency shelters into permanent year-round services and ensuring emergency health plans better account for the needs of homeless people.聽

"They don't have the same resources that other people do in terms of housing, and so I think if ever another pandemic of this sort would happen, we have to think of them before implementing some rules," Gamache said.

This report by 好色tvwas first published May 15, 2025.