Coroner Géhane Kamel was ultimately unable to provide an answer to the circumstances that led to the death of little Thomas Audet, 20 months, which occurred almost seven years ago, in June 2016 in Alma.
Me Kamel delivered her report on the disturbing death of the child on Monday in which she explained that the cause of death was “a blow received directly in the upper part of the abdomen”, but that “the evidence gathered during the investigation does not make it possible to determine the probable cause of the injuries suffered by the child”. In other words, there may never be an answer to the question: how or from whom did he receive this blow?
However, it clearly appears in his report that this is another case that slipped through the cracks of the supervision of the Department of Youth Protection (DPJ).
Reporting a month earlier
A month almost to the day before his death, on May 17, 2016, the DPJ had received a report about him, a report that it had retained and coded “priority 3”, which should have led to treatment at the assessment service within four days. However, according to the testimony of the specialist in clinical activities, “the codes 3 were at that time rather processed within a period of more or less 30 days”.
“Unfortunately, Thomas passed away the day before the summons to a responder,” the report read.
Coroner Géhane Kamel therefore recommends first and foremost that the DYP put in place an exceptional measure so that all children aged 5 and under who are the subject of a report are assessed without delay and monitored daily.
It also recommends that the Ministry of Health and Social Services improve the recruitment and retention of staff, and, in the same logic, “to define precisely the ‘breaking point’ for which the number of reports received is considered to be excessive and decisive for the start of contingency measures”.
Géhane Kamel also asks the College of Physicians to remind its members that the Youth Protection Act obliges any health professional “who, in the practice of his profession, has reasonable cause to believe that the safety or development of a child is or may be considered compromised” to “report the situation without delay” to the DYP.
A fall that explained nothing
The plot of events deserves to be revisited. On June 18, 2016, the infant was first found in her bed, lying on her stomach. His stepfather reportedly gave him his pumps and acetaminophen. Thirty minutes later the child was unconscious and the stepfather would have started resuscitation maneuvers. The death of little Thomas was to be declared after his arrival at the Alma Hospital.
The day before, Thomas allegedly fell from a small bicycle with stationary wheels and fell on the right side of his head. He could not, however, have died as a result of this fall. “Thomas died of a blunt abdominal trauma, explains coroner Kamel. To explain these particular abdominal lesions, the child must have received a blow directly to the upper region of the abdomen. »
A disturbing autopsy report
Certain excerpts from the autopsy report confirm this. It reads, among other things, that on the head, “four contusions were found, one on the forehead on the right side, one at the outer corner of the right eyebrow, one on the left cheek and the last on the side left scalp. […] These injuries are insufficient to explain the death. The pathologist specifies that certain injuries can be explained by the fall from the bicycle, but that this fall cannot explain injuries on both sides of the head.
A little further on, the pathologist’s report is puzzling when he writes that on the abdomen, “various injuries were found. Some are recent, contemporaneous with the death. […] These injuries are the cause of death. […] However, on these recent wounds are juxtaposed old lesions, not contemporaneous with death. […] Thus, this child suffered at least two impacts in the abdomen: one recent, which killed him, and the other old, which had time to heal. »
However, the report made to the DPJ a month earlier said that “the child would have had several worrying injuries since birth and we wonder about the versions given by the parents as well as their supervision”.
Charges dropped
The Sûreté du Québec had investigated this death and charges of manslaughter had been brought four years later, in June 2020, against the stepfather. The Director of Criminal and Penal Prosecutions (DPCP), however, had to request a stay of proceedings on September 29, 2021 since the only witness who had incriminated him had lost all credibility by giving contradictory testimony. The stepfather did not testify at his trial, but did at Ms.e Kamel and he was then put in evidence, when he was asked to describe one by one the events that had injured the child, that for none of them, he was in direct contact with the child.
This extract from the report of Mr.e Kamel clearly outlines the limits of his investigation: “Because of the very great emotional charge associated with tragedies involving children, it is essential to mention that my analysis is in no way intended to determine criminal or civil responsibility. This entire process is intended to shed light and seek the truth about the circumstances surrounding Thomas’ death and the contributing factors. »