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.

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."

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.