Testimony being gathered during the coroner's inquiry into the death of Joyce Echaquan has become increasingly contradictory, as staff members who were working that day give their accounts of events.
Two weeks into the proceedings, the lawyer representing Joyce Echaquan's family, Patrick Martin-Ménard, said "it's difficult to see clearly, to untangle the truth and lies in this."
The coroner's inquiry is looking into the death of Echaquan on Sept. 28 at the Joliette hospital. Hours before she died, the 37-year-old Atikamekw woman posted a video on Facebook of hospital staff verbally abusing her with racist epithets.
On Wednesday, Josée Roch, the head of the hospital's nursing department at the time, said she hadn't seen the video when a social worker came into her office and said a nurse had "called a patient an idiot," and that the video was circulating on social media.
Roch said she went to see the nurse, whose name is protected by a publication ban, and asked her what had happened.
"She smiled at me, and said 'I didn't do anything wrong'," Roch said.
Later that day, Roch testified that she called the nurse into her office after being informed a photo of her was also circulating online.
Roch said she asked the nurse if she wanted to go home, to which the nurse replied she was able to finish her workday.
"And again she said 'anyway I didn't do anything wrong'," Roch told the inquiry.
This is the exact opposite of what the nurse in question testified last week. She told the inquiry she had gone to her boss in tears that day, overwhelmed by what had happened.
She said Roch told her not to worry, that no one would recognize her.
Martin-Ménard said it gives the impression that "everyone is passing the ball, and we're trying to get a clear version of what happened."
Coroner Géhane Kamel said she has been "upset," wondering what would have happened if the video didn't exist.
"Would someone have believed the family?" she asked. "It keeps me awake at night."
"I hope so," Roch answered.
Lack of supervision decried
Earlier in the day, a liaison nurse testified about staffing shortages, an overall difficult work environment and a lack of supervision of junior staff.
Repeated demands to have Echaquan monitored and transferred to a resuscitation room went ignored, according to the nurse, who has more than 20 years of experience and whose name is protected by a publication ban.
When he realized Echaquan had been given five milligrams of the powerful sedative Haldol, was restrained, and wasn't being monitored, he bypassed his direct supervisor and went straight to the head of nursing.
"I wanted to have constant visual and physical monitoring for the patient, from the experience I have for these kinds of cases," said the nurse.
When he walked into Roch's office, he asked if she knew "what was happening with the patient in room 10."
She reportedly replied "we know about the video, we're taking care of it," the nurse testified.
The nurse said he told Roch he didn't know about any video, and didn't care.
"I told her 'We have to move the patient, she isn't where she should be'."
At the time, Echaquan was one of nine patients under the care of a young nursing candidate, who did not yet have her nursing permit.
The nursing candidate testified last week that she had also repeatedly asked to have someone assigned to monitor Echaquan, but those requests went unanswered.
Only one patient attendant was on the floor at the time, while several other staff members had gone for lunch.
By the time the patient attendant was able to check on Echaquan, around 11:45 a.m., her pulse was weak and she was barely breathing.
She was rushed into a resuscitation room, where she was declared dead 40 minutes later.
Chronic staffing shortages
The liaison nurse spent much of his testimony describing the dire working conditions at the Joliette hospital.
Often, the resuscitation unit, which is designed to treat four patients at a time, is occupied by seven patients, with only three nurses, he said.
"When you're running all the time, you can't care for a person, you're just hovering."
The coroner asked him if Joyce Echaquan "paid the price for those staffing shortages?"
"It's clear there wasn't enough staff. It's clear that the person who was responsible for her care wasn't the right person."
The nurse, who was dressed in his scrubs for his testimony, said he was nonetheless proud of the work generally done by his colleagues.
"In 2019, we cared for 66,000 people," he said, tearing up. Employees at the hospital have been "stigmatized" since Echaquan's death, he said, by patients, the population and also by health-care workers in other hospitals.
The nurse concluded his testimony by handing over a list of 25 recommendations to the coroner, to improve training requirements and workflow.