Image source, Getty ImagesImage caption, Ms Echaquan's death incited national outrage
The death of an indigenous woman, Joyce Echaquan, last year was preventable and an "undeniable" case of racism, a Canadian coroner has said.
Ms Echaquan, a mother of seven, died shortly after recording a video of hospital staff insulting her.
In her report, coroner Géhane Kamel found that the woman had died of excess fluid in her lungs.
Staff at the hospital in Joliette, Quebec had incorrectly assumed she was suffering from a narcotics withdrawal.
At a Tuesday press conference to explain the findings of her three-week inquiry, Ms Kamel said Ms Echaquan, who had a history of heart problems, was "infantilised" and labelled as a drug abuser by healthcare staff despite there being no evidence to support this.
This mistaken assumption affected Ms Echaquan's care, Ms Kamel said, and contributed to her death.
Asked if she thought Ms Echaquan would be alive today if she were white, Ms Kamel replied, "I think so" in French.
The coroner, who said the inquiry "shook" her, appeared to hold back tears at some points during the press conference.
Ms Echaquan, a 37-year-old Atikamekw woman, had gone to the Joliette hospital, about 70km (45 miles) from Montreal, suffering from stomach pains. She filmed herself in her hospital bed screaming and calling for urgent help.
In the video, filmed in September 2020, two members of staff are in her room, and one can be heard saying to her, in French: "You're stupid as hell". Another tells her that she made bad choices in life and asks what her children would think of her behaviour.
Both were later fired.
Ms Echaquan's death caused a national outcry and calls for political leaders in Quebec to acknowledge the presence of systemic racism in the province.
Quebec Premier François Legault has called the incident "totally unacceptable" but has denied such racism exists in his province.
A lawyer for Ms Echaquan has said they will soon file a lawsuit over her death, as well as complaints with the province's college of physicians, order of nurses and human rights commission.
Media caption, Joyce Echaquan streamed herself from hospital shortly before her death