Suicide Prevention | “We must intervene better”, decides the coroner

(Montreal) After more than three years of work, the Coroner’s Office unveiled 63 recommendations on Wednesday in its public inquiry report on the theme of suicide.

The coroner M^e 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.

It 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 ensure that mental health is not the poor child of the health system and that the necessary investments are made to achieve it and address 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. M^e 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.