Poor mental health monitoring, key workers who don’t talk to each other, a lack of ongoing training for patrol officers: the deaths of Sergeant Maureen Breau and Isaac Brouillard Lessard could have been avoided, coroner Me Géhane Kamel in his hundred-page report.
She denounced the cruel lack of communication between the health system and the police forces, a real “silo work” where “several red flags were present”, according to her.
“It is distressing to see so many resources around a single individual and so little concerted communication between the various stakeholders over the years,” wrote Mr.e Kamel.
Nearly 40 recommendations were made in the document made public on Monday. They are addressed to the health system, the judicial system, as well as police forces and the Quebec National Police School.
Several of these suggestions aim to add professionals for more effective monitoring of individuals under the mandate of the Mental Disorders Review Commission (CETM), as was the case for Isaac Brouillard Lessard.
It was during an intervention with the young man in Louiseville that Sergeant Maureen Breau lost her life. She was stabbed during the operation. Mr. Brouillard Lessard, a man known to the police for his mental health problems, also died during the incident. The authorities had already intervened with him and he was considered dangerous.
Poor monitoring
Isaac Brouillard Lessard, a man with fragile mental health who had suffered episodes of psychosis in the past, moved several times in recent years. These changes of address revealed the difficulty for health care institutions to follow the trajectory of their users, notes the coroner. Me Géhane Kamel speaks of “communication failures” between establishments.
An excerpt from the report is particularly revealing on this subject: “the last year preceding the fateful evening was punctuated by minimal follow-up by the SIM team (text messages for the vast majority of the follow-up) and marginal psychiatric follow-up (remember that he was not seen for at least five months). At no time did the SIM team or the psychiatrist communicate with the family or the probation officer and despite the legal levers at their disposal, Mr. Brouillard Lessard was not seen for an assessment.”
Better training for police officers
Police officers are on the front lines of the consequences of mental health disorders, the coroner maintains. They must therefore be able to intervene in collaboration with care professionals and social services, stresses Me Kamel.
She recommends that the government improve police training and allow information sharing when required. During the hearings, several police witnesses present during the sergeant’s death explained that they did not have access to certain confidential medical data. However, according to the coroner, information sharing should be done to avoid tragedies.
It is now imperative to ensure that prevention mechanisms are put in place to save lives. Two people have lost their lives and they each leave in their own way an unfinished story for their loved ones.
Excerpt from the coroner’s report
All actors in our society will have to think about their approaches to mental health, concludes M.e Kamel in his voluminous report.
She will address the media at a press briefing on Tuesday morning. This speech will be followed by a press conference by the Sûreté du Québec (SQ), which will react to the report.