Coroner issues report into 'avoidable' killing of Quebec police sergeant

The deaths of a provincial police sergeant and the mentally ill man who stabbed her were avoidable, a Quebec coroner has concluded, saying health-care workers and police should have communicated better.

Ghane Kamel's report, released Monday, includes 38 recommendations for various health, public security and law enforcement groups in connection with the deaths of Sgt. Maureen Breau and Isaac Brouillard Lessard.

On March 27, 2023, Brouillard Lessard fatally stabbed Breau with a kitchen knife and seriously injured another officer before being shot dead by police in his apartment building in Louiseville, Que., about 100 kilometres northeast of Montreal. Brouillard Lessard, 35, suffered from schizoaffective disorder and was killed while police were attempting to arrest him for uttering threats to a family member and breaking probation.

The coroner's inquest heard of numerous failings in the assessment and supervision of Brouillard Lessard, who had been found not criminally responsible because of mental illness five times for offences in 2014 and 2018, and had been followed by the province's mental health board. Witnesses testified that Brouillard Lessard was resistant to treatment and wasn't following court orders regarding his medication.

At a news conference on Tuesday, Kamel said health-care professionals all acted in good faith, but, as he continued to reoffend and move around the province, his case ended up in the hands of too many different people who lacked a full picture of his situation.

The lack of communication between mental health officials and police contributed to Brouillard Lessard's death and that of Breau, a 42-year-old mother of two with more than two decades of policing experience, the coroner said.

"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," Kamel wrote. "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."

The deaths led to the provincial government tabling 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.

Breau was just a handful of shifts away from beginning a new job as an investigator before she was murdered.

On March 24, 2023, three days before Brouillard Lessard killed Breau, his parents had called police because he had inundated his mother with hundreds of text messages and phone calls, some menacing. Officers went to see Brouillard Lessard that day but determined they didn't have reason to detain him.

Then, on March 27, Brouillard Lessard's uncle filed a police complaint over the alleged threats, resulting in the officers' visit to the apartment building.

Lack of follow-up, resources

In her report, Kamel highlighted several red flags concerning Brouillard Lessard that predated Breau's death, notably that he had moved several times over the years and that the health-care network, including the mental health board, was unable to properly keep tabs on him.

In the last year of his life, monitoring by a community mental health team was limited to text messages, and his last psychiatric appointment had been five months before he attacked the sergeant. Kamel said the mental health team and other health workers had the means to assess him for the risk he posed to others, but they never did.

"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.

The coroner said the deaths of Breau and Brouillard Lessard highlight the need for the province's mental health board to revise its approach to following 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."

At a news conference on Tuesday reacting to Kamel's report, Sret du Qubec Chief Inspector Patrice Cardinal said the provincial police force was already on its way to implementing Kamel's recommendations: improving training for officers around use of force and ensuring they are better prepared to respond to calls involving mental illness.

At times emotional, he said he and his colleagues were still grieving Breau's death. "We still feel the emotion," he said.