Four shocking weeks of public inquiry brought to light the smallest details of the fatal chain of events that led to the deaths of officer Maureen Breau and Isaac Brouillard Lessard during a police intervention that turned into a disaster, in Louiseville, in March 2023. An inexorable spiral, but not inevitable: this is the shocking observation that must be drawn from this heartbreaking exercise.
A public inquiry does not seek to distribute blame, but to identify the flaws that led to the irreparable. Coroner Géhane Kamel has never lost sight of this imperative. But with so many flaws exposed in broad daylight, she had to work hard to ensure that the public and the parties called to testify did not fall into this all-too-human trap.
Daniel Sanscartier, Maureen Breau’s partner, summed up the general feeling well: “Obviously, the big conclusion of this investigation is based on two lines: everyone had to talk to each other, but they didn’t really talk to each other. And everyone had to act, but in reality, no one really acted. »
However, many red flags had been raised by the family of the man from 35 years old, who suffered from schizoaffective disorder. Caregivers, police officers, people from his living environment and the legal community had also increased the number of warnings. Everyone preached in the desert, failing to make themselves heard or, more bluntly, to make themselves understood where it counts, when it counts.
The amount of crucial information that fell through the proverbial cracks is staggering. This played a crucial role in the lethal mechanism that was set in motion in the days preceding the operation during which Isaac Brouillard Lessard attacked a police officer before fatally jumping to the neck of Maureen Breau, only to be shot dead by two police officers. Last December, a CNESST investigation report including The duty obtained a copy had highlighted the lack of training of the multiple patrol officers-gendarmes of the Sûreté du Québec.
The question of training came up many times before Coroner Kamel, to whom agent Frédérique Poitras, present during the intervention, asked a difficult question: “Why wouldn’t we have more power? » His question crystallizes a paradox in mental health intervention: how can we ensure the safety of others when we do not feel safe ourselves? The question is a good one for the police, but it is also a good one for all those who work with this complex clientele. We will have to answer it once and for all.
Agent Constant Perreault, also on site that evening, raised another difficult question about communications with 811 and health care providers: what to do when you are turned away in the name of professional secrecy? This is another question which cannot be left unanswered. Those who work with people struggling with mental health problems must be able to dialogue more freely, especially when violence and consumption are present. According to what parameters? This will have to be determined.
The investigation showed that Isaac Brouillard Lessard had been declared not criminally responsible five times for offenses in 2014 and 2018. He had been monitored by the Commission for the Examination of Mental Disorders of Quebec (CETM) since 2014. However, It appeared that this crucial legal structure — whose decisions aim to ensure public safety — is largely unknown, if not unknown, to Quebec police officers. This is nonsense.
The CETM must undergo a major overhaul. Its powers must be enhanced and extended, and its deadlines reduced. More broadly, there is an ambitious reform of the legal guidelines governing mental health care to be carried out. This would make it possible to clarify and better share the immense responsibilities currently incumbent on psychiatrists. “It’s as if we were the guardians of people’s behavior. It’s becoming very heavy,” testified psychiatrist Marie-Frédéric Allard, who crossed paths with Mr. Brouillard Lessard in 2018.
The latter had been living alone for some time in a former hotel converted into a rooming house, where his condition had deteriorated. Supportive housing would have made it possible to monitor him more closely. With so many people in distress and resources as scattered and poorly secured as ours, it is clear that Quebec must provide itself with more structuring environments for these vulnerable clienteles.
Coincidentally, on February 26, coroner Kamel published her report on the violent death of three people shot at random by a man suffering from mental disorders, who was shot by police officers. In particular, she recommended the creation of a court that would specifically deal with cases involving mental illnesses. This new public inquiry not only argues in the same direction, but it highlights its urgent nature. The health and safety of everyone is at stake, including those who watch over us.