'Monitoring by a case manager would have been more than useful to avoid communication failures'
The death of a police officer who was killed by a mentally ill man in Quebec could have been avoided had there been better communication between police and health-care workers, a coroner in the province recently concluded.
On March 27, 2023, 35-year-old Isaac Brouillard Lessard allegedly stabbed to death 42-year-old Sgt. Maureen Breau, according to a Quebec police watchdog officer.
He also left another officer with a skull fracture with a stab wound to the face.
Two other provincial police officers fired at the Brouillard Lessard 19 times, with 11 bullets striking him. He was pronounced dead at a hospital.
The coroner's inquest heard of numerous failings in the assessment and supervision of Brouillard Lessard, reported The Canadian Press in an article posted in the St. Albert Gazette.
Brouillard Lessard had had run-ins with the law in the past. In total, he had four interactions with police officers between December 2022 and March 27, 2023, according to a previous report from CP, posted on CTV News.
He had also been found not criminally responsible five times for offences in 2014 and 2018, and had spent a year at a Montreal psychiatric hospital. His family had requested a first psychiatric consult in 2013.
In April 2022, Brouillard Lessard was granted an absolute discharge and two years probation after assaulting an apartment concierge.
"All of the facts heard in the hearings lead me to conclude that it is entirely likely that the deaths of Sgt. Maureen Breau and Mr. Isaac Brouillard Lessard could have been avoided," coroner Géhane Kamel wrote in his report, according to CP.
"In retrospect, it is distressing to see so many resources focused on the same individual (Brouillard Lessard) and so little concerted communication between the various stakeholders over the years."
Previously, a provincial police officer in Quebec raised the issue of the police not having details from the mental health system that could be a matter of public safety.
After the death of both Breau and Brouillard Lessard, Quebec tables a law in May that includes a budget of $11.3 million over five years for a team of "liaison officers" mandated to monitor people who commit crimes but who are judged to be not criminally responsible because of mental health disorders, and to assess the risk they pose, according to the CP report posted on the St. Albert Gazette.
"Monitoring by a case manager would have been more than useful to avoid communication failures between institutions — and even within the same institution," Kamel wrote.
Kamel also noted that the government should change its approach to surveilling people who are resistant to treatment.
"All the actors in our society will have to think about their approaches to mental health," Kamel said. "The lack of resources is a real problem, but the follow-up structures for people who are resistant are even more so."
