Coroner issues wake-up call in report on Inuk teen moved 78 times by the time she died, at 18

Before ending her life at 18, Maggie Kimattuuti Padlayat was moved 78 times by Quebec's youth protection services.

The constant moving — living with 18 different foster families by the age of seven — contributed to the young Inuk's already aggravated emotional state, and at the same time, it revealed major institutional flaws, according to a coroner's report into Paklayat's death published this week.

Coroner Pascale Boulay suggests several changes the government and its director of youth protection (DPJ) could make to better protect those living in the northern Quebec region, Quebec's Inuit territory of Nunavik.

Among her recommendations, Boulay calls on the province's order of social workers to develop more culturally appropriate practices in working with Inuit youth and ensuring there are Inuit social workers on the front lines.

To do this, she suggests relaxing employment standards for social workers in Inuulitsivik, the health and social services centre serving the seven Inuit communities that hug the east and north coasts of Hudson Bay.

She said when hiring people to work in youth protection services, cultural competence and knowledge of Inuktitut should be recognized as important qualifications.

Found unconscious in foster home

In August 2019, Padlayat was found unconscious in her foster home in the village of Inukjuak. 

After being transported to the Inuulitsivik Health Centre, she was flown more than five hours south, to the Montreal General Hospital.

She was in a neurovegetative state when she was admitted to intensive care, according to Boulay's report. After eight days, the hospital agreed with the young woman's relatives to end active treatment.

She died on Aug. 10, 2019. The coroner determined the death was by suicide.

The teenager never lived with her biological family as she was surrendered at birth, though she did develop positive ties with her family over the years.

But without a permanent foster family, being moved repeatedly was the youth protection service's de facto solution, said Boulay.

"Maggie Padlayat's high number of moves during her childhood is shocking," Boulay wrote. "No child in Quebec should experience these multiple moves."

Lack of foster families part of problem

In her report, the coroner said there is a shortage of foster families in Nunavik, and while this is a problem everywhere in the province, it is particularly striking in northern Quebec, and the consequences are serious.

Boulay said the youth protection service should adapt to the Inuit reality, taking into greater consideration cultural and social factors when assessing each Inuit child's situation.

The coroner's recommendations are also addressed to the Inuulitsivik Health and Social Service Centre, its youth protection service, the order of social workers (OTSTCFQ), the province's social housing agency, the Société de l'habitation du Québec, and the government secretariat serving First Nations and Inuit people, the Secrétariat aux relations avec les Premières Nations et les Inuit.

The president of the OTSTCFQ, Pierre-Paul Malenfant, told Radio-Canada he agrees with Boulay's recommendations.

He has asked the Secrétariat aux relations avec les Premières Nations et les Inuit to make final, as soon as possible, steps aimed at promoting culturally appropriate professional practices and making it easier for Inuit social workers to be hired.

Better adapting such services has been a work in progress for many years, he said. While some steps have been taken, he said, what's left is to improve training and streamline regulatory processes.

"It's very sad. When we see that a young girl has had 78 moves in her short life, we can only deplore the situation," said Malenfant.

"In youth protection, to make a difference, you need to have a stable, ongoing, long-term relationship."

More housing needed

Boulay recommends the Société de l'habitation du Québec and the Quebec minister responsible for Indigenous relations develop an action plan for long-term funding, to create better access to affordable housing in Nunavik for each family and for professionals working in the region.

A spokesperson for the minister, Ian Lafrenière, said in a statement that the government had promised 150 housing units in Nunavik last April to accommodate health-care workers.

By offering better accommodation to health professionals, the hope is to make it easier for health and social service agencies in Nunavut to attract and retain workers, the statement said. 

Nurses who commit to working in the region have also seen their salaries increased by 46.05 per cent, with the same aim of attracting and keeping personnel, it said.

However, Nakuset, the executive director of the Native Women's Shelter of Montreal, said the focus should be on the coroner's recommendation to ensure more Inuit are trained to work as social workers and youth protection workers.

"It needs to be done," Nakuset said. 

"If you're not culturally sensitive, you don't speak the language, the social workers still have preconceived notions about Indigenous people, and that's not helpful."

Empowering the community to learn and apply the tools, "we will have better stories," she said. 

Sending social workers from elsewhere to help the Inuit is only going to lead to the same results, said Nakuset.

Over the last two decades of shelter work, she said she's seen firsthand the difference it makes to have people within Indigenous and Inuit communities trained to help.

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).
• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling on the website.
• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.
• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.