At the end of more than three years of work in the public inquiry into the theme of suicide, the Bureau du coroner unveils 63 recommendations in the hope of better helping people in distress.
The coroner Me Julie-Kim Godin emphasizes that “this vast public inquiry has made it possible to reinforce the need to act upstream”. She writes that great importance must be placed on “early detection of mental health disorders” as well as “substance use” disorders in order to prevent an escalation of problems.
It also insists on the need to take seriously “all people likely to develop a suicidal risk or who present suicidal manifestations”. These people must have “immediate” access to the health services they need.
“We must intervene better and constantly keep in mind that there are no small or big dark ideas,” writes coroner Godin.
What emerges from the entire report is a desire to strengthen the social safety net in order to better support people in distress. The coroner seeks to tighten the meshes by a better coordinated action, the addition of resources and a reinforcement of their competences.
Its dozens of recommendations are aimed at various government departments, police forces, health establishments, community organizations, several professional orders and the National Police Academy.
Me In particular, Godin asks the Ministries of Public Security, Health and Justice to create an advisory committee responsible for reviewing the legal framework surrounding the sharing of confidential information or information protected by professional secrecy.
In another recommendation submitted jointly to Public Security and Health, it proposes to intensify efforts to deploy mixed intervention teams, including police and psychosocial workers, in all regions of Quebec.
It also calls on public authorities to provide “all required resources” to community organizations whose mission is to provide a safety net for people at risk.
“Let’s make sure that mental health is not the poor child of the health system and that the required investments are made to achieve it and respond to the shortage of manpower”, adds the coroner who must meet the journalists during an afternoon press conference.
This public inquiry was ordered by the Chief Coroner of Quebec, Ms.e Pascale Descary, in September 2019. It officially began a few months later, in December, first under the chairmanship of coroner Andrée Kronström. Me Godin took over in October 2021.
Six cases of death by suicide were analyzed by the coroner’s office during this process, namely the files of Mikhaël Ryan, Joceline Lamothe, Suzie Aubé, Jean-François Lussier, Marc Boudreau and Dave Murray.
Numerous witnesses were heard during the hearings, including health professionals, representatives of prevention organizations and bereaved relatives.
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