Death of police officer Maureen Breau | “Several red flags were present and were not considered”

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 M^e Géhane Kamel in his hundred-page report.

Coroner M^e Géhane Kamel denounced the cruel lack of communication between the health system, the judicial system and the police forces, a real “silo work” where “several red flags were present and were not considered”, 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,” writes M.^e Kamel.

In total, 38 recommendations were issued in the document made public Monday. They are addressed to the health system, the courts, as well as police forces and the Quebec National Police School.

It was during an intervention with Isaac Brouillard Lessard, an unstable and criminally involved man, in Louiseville in March 2023 that Sergeant Maureen Breau lost her life. She was stabbed by the suspect during the operation, which was triggered following a call from a loved one.

Mr. Brouillard Lessard, a man known to police for his mental health issues, was shot dead by police officers at the time of the incident. Authorities had already intervened with him in the past and he was considered dangerous.

Poor monitoring

Several of these suggestions aim to add professionals for more effective monitoring of individuals under the mandate of the Mental Disorders Review Board (CETM), as was the case for Isaac Brouillard Lessard. The CETM is responsible for assessing the mental state of an accused to determine whether he or she is fit to stand trial, but also for assessing risk and ensuring follow-up with individuals found not criminally responsible due to mental disorders.

Isaac Brouillard Lessard, a real time bomb, has moved several times in recent years. These changes of address have revealed the difficulty for health care institutions to follow the trajectory of their users, notes the coroner. M^e Géhane Kamel speaks of “communication failures” between establishments.

An excerpt from the report is particularly revealing on this subject:

“The last year leading up to the fateful evening was punctuated by minimal follow-up by the SIM team [programme Suivi intensif dans le milieu, destiné aux cas graves en santé mentale] (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 will the SIM team or the psychiatrist communicate with the family or the probation officer and despite the legal levers they have in their hands, Mr. Brouillard Lessard will not be seen for an assessment.

In this sense, the coroner also advocates for greater inclusion of parents and caregivers in the treatment process – police and medical – of people struggling with mental health problems.

“Throughout this investigation, one thought has haunted me repeatedly. The voice of families. The one that gets lost in the twists and turns of state systems. […] They are the best equipped to talk about a loved one, they are also the ones who know them best. We should therefore focus on this when these families raise red flags,” writes M.^e Kamel in his report.

Better training for police officers

Police officers must be able to intervene in collaboration with healthcare professionals and social services in serious mental health cases such as that of Isaac Brouillard Lessard, stresses M.^e Kamel.

She therefore 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, the sharing of information – “inadequate” in this case – should be done to avoid tragedies.

By email, the College of Physicians said it was “in favour of the patient’s relevant medical information being communicated, if necessary and in a secure manner, to members of the police force”, but said it wanted to “take the time to read the report in its entirety” before commenting on it in a more substantial manner.

All actors in our society will have to think about their approaches to mental health, concludes M.^e Kamel in his voluminous report.

“The balance is therefore fragile; we must certainly avoid the trap of stigmatization and perceive the other more globally as a person, to rehumanize him, by not reducing him to his mental health disorder, while protecting the population.”

She will address the media at a press briefing this Tuesday morning. This speech will be followed by a press conference by the Sûreté du Québec (SQ), which will react to the report.

“It’s almost unanimous”

Having himself been heard by the coroner for the writing of the report, former police officer Stéphane Wall is delighted with the 38 or so recommendations found therein.

In addition to the aspects of consultation and communication, the former police officer from the Montreal Police Department is also in tune with the coroner regarding the importance of training. He emphasizes the establishment of “mentors”, whose scope of action will be primarily local and who will be able to support the various police forces in a more targeted perspective, an idea that he had defended before Mr.^e Kamel: Such a proposal is crucial for him to better assess risks, particularly in situations that affect mental health.

In his report, Mr.^e Kamel also recommends that the SQ set up multidisciplinary training centres for remote MRCs and add an additional day per year (four in total) to maintain police intervention skills, with particular emphasis on de-escalation.

While he also wants better training, the former police officer has a reservation about the implementation of these recommendations in the near future, while the police community in Quebec is struggling with a significant shortage of personnel. “Four days of training per year for 3,000 police officers [comme le propose M^e Kamel]that’s 12,000 working days… [alors qu’on] already has trouble training new police officers.”

Despite the logistical difficulties associated with implementing some of the recommendations, Mr Wall nevertheless reiterates that “what makes the effectiveness and retention of knowledge and good practices is repetition”, and that the role of maintaining skills is therefore crucial.