custody_death · 2023-Q3
Bureau du coroner (Québec) · Bureau du coroner du Québec
Redacted summary
A man died from asphyxiation by obstruction of the upper airways in a temporary transitional resource center in Montreal. He had a known swallowing disorder and risk of choking. The circumstances surrounding the death, including the lack of adequate surveillance and delays in emergency intervention, raise questions about the evaluation of user needs, collaboration, and information sharing between teams, as well as the management of emergency situations to ensure user safety.
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