The deaths of Sergeant Maureen Breau and Isaac Brouillard Lessard “could have been avoided,” concluded coroner Géhane Kamel, in a hundred-page report published Monday.
“There were several red flags present that were not considered,” wrote the coroner, who looked into the two deaths as part of a public inquiry last February.
The coroner, who issued 38 recommendations, deplored the lack of communication between the various people involved in the case of Isaac Brouillard Lessard, a 35-year-old man suffering from schizoaffective disorder who had been declared not criminally responsible five times since 2013.
“In retrospect, it is distressing to see so many resources focused on the same individual and so little concerted communication between the various stakeholders over the years. This silo work is in fact the backdrop to the entire history that surrounded Mr. Brouillard Lessard’s care and contributed to his death and the death of Ms.me Breau. »
The coroner’s investigation revealed that his parents had called 911 in the days before the tragedy to warn them that he was psychotic and dangerous. The police officers who arrived at the scene found him to be relatively calm and left the scene without further intervention. In the following days, other police officers, including Officer Maureen Breau, returned to the scene to arrest him following further threats. The man then stabbed two officers before being shot. Officer Maureen Breau did not survive the attack.
“Our duty to remember must be accompanied by societal reflection and it is now imperative to ensure that prevention mechanisms are put in place to save lives,” concluded the coroner. “Two people lost their lives and they each leave in their own way an unfinished story for their loved ones.”
More details will follow.
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