Read the list: Coroner's recommendations to prevent another death like Joyce Echaquan's

Coroner Gehane Kamel investigated the death of Joyce Echaquan and issued several recommendations after finding that her death was accidental but preventable.

Kamel concluded that the racism and prejudice the Indigenous woman was subjected to contributed to her death on Sept. 28, 2020, at a hospital in Joliette, Que., northeast of Montreal.

Here is a look at some of Kamel's more specific recommendations:

For the Quebec government

-- Recognize the existence of systemic racism within our institutions and make a commitment to contribute to its elimination.

For the regional health authority that governs the hospital in Joliette, Que., where Echaquan died

-- Ensure the effective integration of the Atikamekw liaison officer into the hospital, in particular by involving them with care teams.

-- Ensure notes in medical files reflect the reality of how patients are being cared for.

-- Review the nurses-to-orderlies ratio based on standards recognized at the provincial level in order to provide safe services to the population.

-- Maintain periodic training on the establishment's code of ethics, restraint measures, the monitoring of patients following a fall, and record management.

-- Quickly set up training and activities for the inclusion of Indigenous culture that is coordinated with the community of Manawan.

-- Improve the nurse/nursing assistant model and ensure that each has a clear understanding of their roles.

For the College des medecins du Quebec, the province's order of physicians

-- Review the quality of the medical care given by the doctor responsible for family medicine and by the medical resident in gastroenterology to Ms. Echaquan during her hospitalization in September 2020.

For the Ordre des infirmieres et infirmiers du Quebec, the province's nurses order

-- Examine the quality of care of nurses' services provided to Ms. Echaquan during her hospitalization.

-- Review the integration practices of college-level nursing candidates in emergency departments across hospitals in the province.

For the Department of Higher Education and its institutions that train doctors, nurses and nursing assistants

-- Include in the school curriculum training on the care of Indigenous patients that takes into consideration the realities of Indigenous communities.

-- Establish with Indigenous communities a greater offer of internships for both nurses and medical residents.

This report by The Canadian Press was first published Oct. 5, 2021.

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