A 72-year-old homeless man died by an icy evening in December 2022 in Val-d’Or “had no real safety net”, concludes the Coroner. The man has spent the last year of his life to come up against the “rotating doors” of the health network.
The report of the Coroner Stéphanie Gamache, made public Thursday, describes the sad life of Gilles Gaouette, a traumatized man who has become dependent on alcohol and anxiolytics after being injured by bullet around the age of 20.
He was expelled from his apartments, then from his residence for the elderly in August 2022 because of his aggressiveness and his frantic alcohol consumption. Briefly hosted with his son in Senneterre, he later fell “homelessness” in early December 2022, after his return to Val-d’Or.
He multiplies visits to an emergency and it was after one of the consultations, on December 11, 2022, that he was discovered on the ground near the door of emergency parking. He will be declared dead at 8:15 p.m. of a myocardial infarction.
Photo taken from the site of the Abitibi funeral cooperative
Gilles Gaouette, died at the age of 72
“No one should end their life in this way,” writes Coroner Stéphanie Gamache. Mr. Gaouette’s journey in the last 11 months of her life has been imbued with pain, suffering, incomprehension and residential insecurity since no one could diagnose their dependence on benzodiazepines. »»
Hearings on the circumstances of his death were held in November 2024, in which around twenty witnesses and experts participated.
The Coroner office declined the requests for The press.
“More severe” than his alcoholism
Crucial point, the dependence of Mr. Gaouette to benzodiazepines was poorly diagnosed. He had taken these anxiolytics for decades, which can explain his confusion. The majority of stakeholders who faced his mood swings and his refusal to be treated rather attributed his condition to alcohol.
Better management of his dependence problem, and more particularly his dependence on benzodiazepines, would possibly have made a difference in Mr. Gaouette’s care and services.
Coroner Stéphanie Gamache in her report
The Coroner is also surprised that an organization, the Norman Center, “the specialist in dependence in Abitibi-Témiscamingue”, has never focused on this dependence on benzodiazepines “which seems to have been more severe than its chronic alcohol use disorder”.
She specifies that she does not throw any blame on the many speakers who met Mr. Gaouette. “All stakeholders […] acted at the best of their knowledge and skills with kindness and good faith. “It however identifies” size structural challenges “in the health network.
A first report of three
The Coroner notes, for example, that, for lack of monitoring and centralized management of his medical file of “nearly 1000 pages”, Mr. Gaouette found himself on dozens of covers in the emergency of the Val-d’Or hospital.
“He is a long-standing user of the emergency department of the Val-d’Or hospital”, where we report his “chronic ethylism”. “The numerous visits invariably end up in his hasty departure when he has drawn up and generate great use of care by this user, a phenomenon commonly called” rotating doors “,” explains Me Gamache.
La Coroner goes there with 18 recommendations, all aimed at better care for vulnerable users or roaming.
In particular, she suggests that we develop the function of “case manager or pivotal worker” and that “outing plans” are established after a transition to emergency.
“Despite all the efforts of the various services […]none have been able to ensure a real care for Mr. Gaouette, notes the Coroner. The latter cannot be held for solely responsible for his fate. »»
The investigation into the death of Gilles Gaouette was the first of the three which were announced in November 2024, after users who received care at the Val-d’Or hospital was found dead.
On November 17, hearings will be held on the death of Pasha Ekoomiak, which occurred on February 8, 2023. As for the third user, Rayden Anichinape-Pien, who died on December 29, 2022, he will be the subject of a investigation and a report “without having recourse to public hearings”, it is said at the Coroner office.
